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

conTemporary reflectiOns regarding heart failure manaGEmenT - How to ovERcome the PorTuguese barriers (TOGETHER-PT)

INTRODUCTION AND OBJECTIVES

Heart failure (HF) is a complex clinical syndrome that is a significant burden in hospitalisations, morbidity, and mortality. Although a significant effort has been made to better understand its consequences and current barriers in its management, there are still several gaps to address. The present work aimed to identify the views of a multidisciplinary group of health care professionals on HF awareness and literacy, diagnosis, treatment and organization of care, identifying current challenges and providing insights into the future.

METHODS

A steering committee was established, including members of the Heart Failure Study Group of the Portuguese Society of Cardiology (GEIC-SPC), the Heart Failure Study Group of the Portuguese Society of Internal Medicine (NEIC-SPMI) and the Cardiovascular Study Group (GEsDCard) of the Portuguese Association of General and Family Medicine (APMGF). This steering committee produced a 16-statement questionnaire regarding different HF domains that was answered to by a diversified group of 152 cardiologists, internists, general practitioners, and nurses with an interest or dedicated to HF using a five-level Likert scale. Full agreement was defined as ≥80% of level 5 (fully agree) responses.

RESULTS

Globally, consensus was achieved in all but one of the 16 statements. Full agreement was registered in seven statements, namely 3 of 4 statements for patient education and HF awareness and 2 in 4 statements of both HF diagnosis and healthcare organization, with proportions of fully agree responses ranging from 82.9% to 96.7%. None of the HF treatment statements registered full agreement but 3 of 4 achieved ≥80% of level 4 (agree) responses.

CONCLUSION

This document aims to be a call-to-action to improve HF patients' quality of life and prognosis, by promoting a change in HF care in Portugal.

Unlocking Continuous Improvement in Heart Failure Remote Monitoring: A Participatory Approach to Unveil Value Dimensions and Performance Indicators

Introduction: Heart failure (HF) constitutes a public health concern affecting quality of life, survival, and costs. Remote patient monitoring (RPM) can enhance HF management, involving patients actively and improving follow-up. While current HF RPM assessments emphasise cost-effectiveness analysis, there is a need to consider wider RPM impacts and integrate stakeholders' perspectives into assessments for better comprehensiveness. Methods: We developed a four-stage participatory approach to select value dimensions and indicators for continuous HF RPM assessment: Stage 1 involved building a literature-informed initial list; Stage 2 utilized expert interviews for validation and list expansion; Stage 3 involved a web-Delphi process with Portuguese stakeholders and experts for agreement assessment; and Stage 4 included a conclusive expert interview. Results: A literature review identified fourteen studies on telehealth, RPM, and HF, informing an initial list of four value dimensions (Access, Clinical aspects, Acceptability, and Costs) and 22 indicators. Seven semistructured interviews validated and further adjusted the list to 38 indicators. Subsequently, the web-Delphi process engaged 29 stakeholders, giving their opinions regarding assessment aspects' relevance and proposing additional elements - 1 dimension and 12 indicators. Five value dimensions and 38 indicators (76.0%) reached group agreement for selection, while 12 did not reach an agreement. Upon expert appreciation, 5 dimensions, 43 indicators, and 6 case-mix parameters were considered relevant. Discussion: This comprehensive social approach captured diverse stakeholder perspectives, achieving agreement on pertinent HF RPM monitoring and evaluation indicators. Findings can inform visualization and management tool development, aiding day-to-day RPM evaluation and identification of improvement opportunities.

A cost-effectiveness analysis of empagliflozin for heart failure patients across the full spectrum of ejection fraction in Spain: combined results of the EMPEROR-Preserved and EMPEROR-Reduced trials

BACKGROUND

Heart failure (HF) is a chronic condition with considerable clinical burden for patients and economic burden for healthcare systems. Treatment for HF is typically based on ejection fraction (EF) phenotype. The cost-effectiveness of empagliflozin + standard of care (SoC) compared to SoC has been examined for HF phenotypes below or above 40% EF separately, but not across the full spectrum of EF in Spain.

METHODS

The results of two preexisting, validated, and published phenotype-specific Markov cohort models were combined using a population-weighted approach, reflecting the incidence of each phenotype in the total HF population in Spain. A probabilistic sensitivity analysis was performed by sampling each model's probabilistic results.

RESULTS

Empagliflozin + SoC compared to SoC resulted in increased life-years (LYs) (6.48 vs. 6.35), quality-adjusted LYs (QALYs) (4.80 vs. 4.63), and healthcare costs (€19,090 vs. €18,246), over a lifetime time horizon for the combined HF population in Spain. The incremental cost-effectiveness ratio (ICER) was €5,089/QALY. All subgroup, scenario, and probabilistic ICERs were consistently below €10,000/QALY.

CONCLUSIONS

Empagliflozin is the first treatment with established efficacy and cost-effectiveness for HF patients across EF from the perspective of healthcare payers in Spain. Empagliflozin also proved to be cost-effective for all subgroups of patients included in the analysis.

Portuguese Heart Failure Prevalence Observational Study (PORTHOS) rationale and design - A population-based study

INTRODUCTION AND OBJECTIVES

Current epidemiological data on heart failure (HF) in Portugal derives from studies conducted two decades ago. The main aim of this study is to determine HF prevalence in the Portuguese population. Using current standards, this manuscript aims to describe the methodology and research protocol applied.

METHODS

The Portuguese Heart Failure Prevalence Observational Study (PORTHOS) is a large, three-stage, population-based, nationwide, cross-sectional study. Community-dwelling citizens aged 50 years and older will be randomly selected via stratified multistage sampling. Eligible participants will be invited to attend a screening visit at a mobile clinic for HF symptom assessment, anthropomorphic assessment, N-terminal pro-B-type natriuretic peptide (NT-proBNP) testing, one-lead electrocardiogram (ECG) and a sociodemographic and health-related quality of life questionnaire (EQ-5D). All subjects with NT-proBNP ≥125 pg/mL or with a prior history of HF will undergo a diagnostic confirmatory assessment at the mobile clinic composed of a 12-lead ECG, comprehensive echocardiography, HF questionnaire (KCCQ) and blood sampling. To validate the screening procedure, a control group will undergo the same diagnostic assessment. Echocardiography results will be centrally validated, and HF diagnosis will be established according to the European Society of Cardiology HF guidelines. A random subsample of patients with an equivocal HF with preserved ejection fraction diagnosis based on the application of the Heart Failure Association preserved ejection fraction diagnostic algorithm will be invited to undergo an exercise echocardiography.

CONCLUSIONS

Through the application of current standards, appropriate methodologies, and a strong research protocol, the PORTHOS study will determine the prevalence of HF in mainland Portugal and enable a comprehensive characterization of HF patients, leading to a better understanding of their clinical profile and health-related quality of life.

Impact of a heart failure multidisciplinary clinic on the reduction of healthcare-related events and costs: the GEstIC study

Introduction

Heart failure (HF) is the leading cause of hospitalization in the elderly in developed countries and significantly impacts public health expenditures. Patients with HF usually have associated comorbidities that require multidisciplinary management. This study aims to demonstrate the benefits of a multidisciplinary clinic in reducing all-cause hospitalizations and HF events (HF hospitalizations and urgent HF visits) in a real-world setting. Finally, the study evaluates the associated costs of HF events.

Methods

This observational study included patients admitted to GEstIC, a multidisciplinary Portuguese HF clinic, from January 2013 to February 2019, who had one-year follow-up. Hospitalizations and HF events, total days spent in the hospital during HF hospitalizations, and HF events-related costs, in the year before and the year after GEstIC admission, were compared.

Results

Of the 487 patients admitted to the GEstIC, 287 were eligible for the study sample. After one year of HF patients' multidisciplinary management at GEstIC, there was a 53.7% reduction in all-cause hospitalizations (462 vs. 214), a 71.7% reduction in HF hospitalizations (392 vs. 111), and a 39.1% reduction in urgent HF visits (87 vs. 53). As a result, there was a significant decrease of 12.6 days in the length of hospital stay due to HF per patient (15.6 vs. 3.0, p < 0.001). This translated into the release of 9.9 hospital beds in the year following admission to GEstIC. The average total savings associated with the reduction of HF events was €5,439.77 per patient (6,774.15 vs. 1,334.38, p < 0.001), representing a total cost reduction of €1,561,213. Furthermore, the significant reduction in the number of all events was independent of the patient's left ventricular ejection fraction (LVEF).

Discussion

Significant reductions in all-cause and HF hospitalizations and urgent HF visits were observed with the implementation of this multidisciplinary clinic for HF patients' management. This was particularly important for patients with LVEF >40%. Before GEstIC, there was no medical intervention to improve the prognosis of these patients. The reduction of over one million euros in health-related costs after only one year of person-centered multidisciplinary management highlights the need to replicate this approach in other national healthcare institutions.

A cross-sectional study of echocardiographic characteristics of patients diagnosed with SARS-CoV-2 delta strain

BACKGROUND

The delta variant of SARS-CoV-2 has been associated with increased mortality and multi-organ failure, affecting various systems in the body. Cardiovascular manifestations including arrhythmias, heart failure, myocarditis, myocardial damage, and thromboembolism are commonly observed in patients infected with the delta variant.

MATERIALS AND METHODS

This study enrolled 106 individuals who tested positive for the delta strain of SARS-CoV-2 using real-time RT-PCR between May 25, 2020, and October 15, 2021. All patients underwent 2-D echocardiography, and based on the severity of their infection, were divided into two groups: serious and non-serious.

RESULTS

Univariate correlation analysis showed significant positive correlations between right ventricular (RV) diameter and hs-TnI and D-dimer levels. Conversely, left ventricular ejection fraction (LVEF) was negatively correlated with hs-TnI, C-reactive protein (CRP), and D-dimer levels. Additionally, RV fractional area change (RV-FAC) showed a negative correlation with D-dimer and hs-TnI levels but not with CRP levels.

DISCUSSION

RV dysfunction has been identified as an important predictor of mortality in various patient populations, including those infected with the delta variant of SARS-CoV-2. A significant proportion of severe delta variant cases require mechanical ventilation, which can have hemodynamic effects on the ventricular performance. Mechanical ventilation can increase pulmonary arterial pressure and worsen right heart dysfunction, especially when lung-protective ventilation strategies are not optimized.

CONCLUSIONS

Our study highlights that patients with severe delta variants, particularly those with cardiac injury, may exhibit biventricular systolic dysfunction. Echocardiographic parameters such as LVEF, RV diameter, and RV-FAC were found to be associated with laboratory markers of poor prognosis, including elevated hs-TnI, CRP, and D-dimer levels. 2-D echocardiography can be a valuable tool in identifying early signs of ventricular dysfunction, aiding in the management of this patient population.

Primary care in supplementary health: assessment of costs in the care of older adult patients with heart diseases

OBJECTIVES

to identify whether implementing a supplementary Primary Health Care (PHC) system makes it possible to reduce care costs for older adults with heart diseases.

METHODS

a retrospective cohort of 223 patients with heart disease aged ≥ 60 years. Data were obtained from medical records and cost databases, assessed for a period of one year before and after PHC implementation. The results were expressed as mean absolute frequencies for number of hospitalizations and as average annual expenses expressed in dollars (US$) in relation to cost data.

RESULTS

there was a reduction in hospitalization expenses after implementing supplementary PHC (p=0.01) and a decrease in the frequency of hospitalizations for the entire sample (p=0.006). There was a reduction in the frequency of consultations at the Emergency Room among frail older adults (p=0.011).

CONCLUSIONS

there was a reduction in hospitalization costs and frequency of visits to the Emergency Room after supplementary PHC.

Telemonitoring in Portugal: where do we stand and which way forward?

Following the pandemic, there is growing pressure in Portugal to adopt new practices that promote more efficient, sustainable, and equitable healthcare. Telemonitoring (TM) has been identified as a valuable solution, particularly for chronically ill, long-term or socially isolated patients. Several initiatives have since emerged. Thus, Portuguese stakeholders recognise the need to reflect upon TM's current state and prospects. This study aims to provide a comprehensive analysis of the TM landscape in Portugal. We begin by analysing the underlying conditions for telehealth development. Then, we describe the governmental strategy and priorities towards TM - the National Strategic Plan for Telehealth development and NHS reimbursement opportunities for TM. To understand TM implementation, adoption, and dissemination in Portugal, we analyse 46 reported initiatives and adoption studies focusing on providers' perspectives. Finally, a structured reflection on current challenges and the way forward is provided, according to the seven domains of the Nonadoption, Abandonment, and challenges to the Scale-up, Spread, and Sustainability (NASSS) framework. The adoption of TM by Portuguese institutions has been growing, leveraged by the telehealth governance model and public reimbursement mechanisms, proving particularly relevant during the pandemic. However, monitored patients are still few. Low digital literacy among patients and providers, lack of care integration and resource scarcity represent barriers hampering pilot TM initiatives' scale-up.

Real-Life Data on Readmissions of Worsening Heart Failure Outpatients in a Heart Failure Clinic

Introduction Recurrent hospitalizations for worsening heart failure (WHF) represent a major global public health concern, resulting in significant individual morbimortality and socioeconomic costs. This real-life study aimed to determine the rate and predictors of readmission for WHF in a cohort of outpatients with chronic heart failure (CHF) followed in a heart failure clinic (HFC) at a university hospital. Methods We conducted a longitudinal, observational, and retrospective study of all consecutive CHF patients seen at the HFC of the São Francisco Xavier Hospital, Lisbon, by a multidisciplinary team in 2019. The patients were followed for one year and were on optimized therapy. The inclusion criteria for the study were patients who had been hospitalized and subsequently discharged at least three months prior to their enrollment. Patient demographics, heart failure (HF) characterization, comorbidities, pharmacological treatment, treatments of decompensated HF in the day hospital (DH), hospitalizations for WHF, and death were recorded. We applied logistic regression analysis to assess predictors of hospital readmission for HF. Results A total of 351 patients were included: 90 patients (26%) had WHF requiring treatment with intravenous diuretics in the DH; 45 patients (mean age: 79.1 ± 9.0 years) were readmitted for decompensated HF within one year (12.8%) with no gender difference, while 87.2% of the patients (mean age: 74.9 ± 12.1 years) were never readmitted. Readmitted patients were significantly older than those who were not (p=0.031). Additionally, they had a higher New York Heart Association (NYHA) functional classification (p<.001), were on a higher daily dose of furosemide (p=0.008) at the time of the inclusion visit, were more frequently affected by the chronic obstructive pulmonary disease (COPD) (p=0.004); had been treated more often in the DH for WHF (p<.001) and had a higher mortality rate (p<.001) at one year. Conclusions This study aimed to determine WHF patient readmission rates and predictors. According to our results, a higher NYHA class, the need for treatment in the DH for WHF, a daily dose of furosemide equal to or greater than 80 mg, and COPD were predictors of readmission for WHF. CHF patients continue to experience WHF and recurrent hospitalizations despite therapeutic advances and close follow-up in the HFC with the multidisciplinary team. Besides COPD, the HF readmission risk factors found were mainly related to advanced disease. Furthermore, the structured and multidisciplinary approach of our disease management program likely contributed to our relatively low rate of readmissions.

Ganhos com o programa de reabilitação e ensino à pessoa com insuficiência cardíaca (Programa REPIC)

Introdução: Apesar dos avanços no tratamento, a insuficiência cardíaca é uma doença crónica, cuja incidência aumenta com a idade. Os internamentos por descompensação mantêm-se elevados, pelo que é crucial priorizar estratégias para a autogestão, tais como o ensino, o acompanhamento e os programas de reabilitação cardíaca. Face ao exposto, este estudo teve como objetivo verificar o impacto do programa REPIC na qualidade de vida, nível de conhecimentos e adesão ao exercício físico. Metodologia: Estudo quantitativo com desenho antes-após de grupo único realizado numa amostra de 110 pessoas com insuficiência cardíaca, sujeitos a um programa de reabilitação e educação para a saúde durante o internamento e com follow-up telefónico, ao final de um mês, seis meses e um ano após a alta clínica. Resultados e Discussão: A maioria dos participantes são do sexo masculino (66%) e a amplitude da idade varia entre 30 e 89, com uma média de 64,3 anos e um desvio padrão de 14,4. A análise dos dados evidenciou uma melhoria estatisticamente significativa no conhecimento sobre a doença, bem como na perceção da qualidade de vida nas dimensões mobilidade, cuidados pessoais, atividades habituais e nível geral de saúde (p=0,01). O incremento no tempo de exercício físico após o programa REPIC foi confirmado com resultado estatisticamente significativo [t (109)=6,03; p=0,019]. Os resultados obtidos demonstram os benefícios da educação para a saúde e do acompanhamento telefónico de enfermagem, nomeadamente a melhoria no nível de conhecimentos sobre a doença, na qualidade de vida e na adesão ao exercício físico.  Conclusão: O programa REPIC permitiu reforçar o processo educativo, potenciar os comportamentos de autogestão, melhorar a qualidade de vida e aumentar a duração do exercício físico.

Global burden of heart failure: a comprehensive and updated review of epidemiology

Heart Failure (HF) is a multi-faceted and life-threatening syndrome characterized by significant morbidity and mortality, poor functional capacity and quality of life, and high costs. HF affects more than 64 million people worldwide. Therefore, attempts to decrease its social and economic burden have become a major global public health priority. While the incidence of HF has stabilized and seems to be declining in industrialized countries, the prevalence is increasing due to the ageing of the population, improved treatment of and survival with ischaemic heart disease, and the availability of effective evidence-based therapies prolonging life in patients with HF. There are geographical variations in HF epidemiology. There is substantial lack of data from developing countries, where HF exhibits different features compared with that observed in the Western world. In this review, we provide a contemporary overview on the global burden of HF, providing updated estimates on prevalence, incidence, outcomes, and costs worldwide.

Levosimendan in outpatients with advanced heart failure: Single-center experience of 200 intermittent perfusions

INTRODUCTION

Patients with advanced heart failure (HF) have high morbidity and mortality, with only a small proportion being eligible for advanced therapies. Intermittent outpatient levosimendan infusion has been shown to provide symptomatic relief and reduce the rate of HF events. Our aim was to assess the safety and efficacy of outpatient levosimendan administration in an advanced HF population.

METHODS

This is a report of a single-center experience of consecutive advanced HF patients referred for intermittent intravenous outpatient administration of levosimendan, between January 2018 and March 2021. Baseline and follow-up evaluation included clinical assessment, laboratory tests, transthoracic echocardiography and cardiopulmonary exercise testing. Baseline and clinical follow-up data were compared using the Wilcoxon signed-rank test.

RESULTS

A total of 24 patients (60.8 years, 83% male, mean left ventricular ejection fraction [LVEF] 24%), with a median of 1.5 HF hospitalizations in the previous six months, were referred for outpatient levosimendan pulses, the majority as a bridge to transplantation or due to clinical deterioration. At six-month follow-up there was a significant reduction in HF hospitalizations to 0.4±0.7 (p<0.001). NYHA class IV (52.2% to 12.5%, p=0.025) and NT-proBNP (8812.5 to 3807.4 pg/ml, p=0.038) were also significantly reduced. Exercise capacity was significantly improved, including peak oxygen uptake (p=0.043) and VE/VCO₂ slope (p=0.040). LVEF improved from 24.0% to 29.7% (p=0.008). No serious adverse events were reported.

CONCLUSION

Repeated levosimendan administration in advanced HF patients is a safe procedure and was associated with a reduction in HF hospitalizations, functional and LVEF improvement, and reduction in NT-proBNP levels during follow-up.

Impact analysis of heart failure across European countries: an ESC-HFA position paper

Heart failure (HF) is a long-term clinical syndrome, with increasing prevalence and considerable healthcare costs that are further expected to increase dramatically. Despite significant advances in therapy and prevention, mortality and morbidity remain high and quality of life poor. Epidemiological data, that is, prevalence, incidence, mortality, and morbidity, show geographical variations across the European countries, depending on differences in aetiology, clinical characteristics, and treatment. However, data on the prevalence of the disease are scarce, as are those on quality of life. For these reasons, the ESC-HFA has developed a position paper to comprehensively assess our understanding of the burden of HF in Europe, in order to guide future policies for this syndrome. This manuscript will discuss the available epidemiological data on HF prevalence, outcomes, and human costs-in terms of quality of life-in European countries.

Prevalence, Characteristics, Management and Outcomes of Patients with Heart Failure with Preserved, Mildly Reduced, and Reduced Ejection Fraction in Spain

Objective: To estimate the prevalence, incidence, and describe the characteristics and management of patients with heart failure with preserved (HFpEF), mildly reduced (HFmrEF), and reduced ejection fraction (HFrEF) in Spain. Methods: Adults with ≥1 inpatient or outpatient HF diagnosis between 1 January 2013 and 30 September 2019 were identified through the BIG-PAC database. Annual incidence and prevalence by EF phenotype were estimated. Characteristics by EF phenotype were described in the 2016 and 2019 HF prevalent cohorts and outcomes in the 2016 HF prevalent cohort. Results: Overall, HF incidence and prevalence were 0.32/100 person-years and 2.34%, respectively, but increased every year. In 2019, 49.3% had HFrEF, 38.1% had HFpEF, and 4.3% had HFmrEF (in 8.3%, EF was not available). Compared with HFrEF, patients with HFpEF were largely female, older, and had more atrial fibrillation but less atherosclerotic cardiovascular disease. Among patients with HFrEF, 76.3% were taking renin-angiotensin system inhibitors, 69.5% beta-blockers, 36.8% aldosterone antagonists, 12.5% sacubitril/valsartan and 6.7% SGLT2 inhibitors. Patients with HFpEF and HFmrEF took fewer HF drugs compared to HFrEF. Overall, the event rates of HF hospitalization were 231.6/1000 person-years, which is more common in HFrEF patients. No clinically relevant differences were found in patients with HFpEF, regardless EF (50- < 60% vs. ≥60%). Conclusions: >2% of patients have HF, of which around 50% have HFrEF and 40% have HFpEF. The prevalence of HF is increasing over time. Clinical characteristics by EF phenotype are consistent with previous studies. The risk of outcomes, particularly HF hospitalization, remains high, likely related to insufficient HF treatment.

20 Years of Real-World Data to Estimate the Prevalence of Heart Failure and Its Subtypes in an Unselected Population of Integrated Care Units

Introduction: Heart failure (HF) is a clinical syndrome caused by structural and functional cardiac abnormalities resulting in the impairment of cardiac function, entailing significant mortality. The prevalence of HF has reached epidemic proportions in the last few decades, mainly in the elderly, but recent evidence suggests that its epidemiology may be changing. Objective: Our objective was to estimate the prevalence of HF and its subtypes, and to characterize HF in a population of integrated care users. Material and Methods: A non-interventional cross-sectional study was performed in a healthcare center that provides primary, secondary and tertiary health cares. Echocardiographic parameters (left ventricle ejection fraction (LVEF) and evidence of structural heart disease) and elevated levels of natriuretic peptides were used to define two HF phenotypes: (i) HF with a reduced ejection fraction (HFrEF, LVEF ≤ 40% and either NT-proBNP ≥ 400 pg/mL (≥600 pg/mL if atrial fibrillation (AF)/flutter) or BNP ≥ 100 pg/mL (≥125 pg/mL if AF/flutter)) and (ii) HF with a non-reduced ejection fraction (HFnrEF), which encompasses both HFpEF (LVEF ≥ 50% and either NT-proBNP ≥ 200 pg/mL (≥600 pg/mL if AF/flutter) or BNP ≥ 100 pg/mL (≥125 pg/mL if AF/flutter) in the presence of at least one structural cardiac abnormality) and HF with a mildly reduced fraction (HFmrEF, LVEF within 40−50% and either NT-proBNP ≥ 200 pg/mL (≥600 pg/mL if AF/flutter) or BNP ≥ 100 pg/mL (≥125 pg/mL if AF/flutter) in the presence of at least one structural cardiac abnormality). The significance threshold was set at p ≤ 0.001. Results: We analyzed 126,636 patients with a mean age of 52.2 (SD = 18.3) years, with 57% (n = 72,290) being female. The prevalence of HF was 2.1% (n = 2700). The HF patients’ mean age was 74.0 (SD = 12.1) years, and 51.6% (n = 1394) were female. Regarding HF subtypes, HFpEF accounted for 65.4% (n = 1765); 16.1% (n = 434) had HFmrEF and 16.3% (n = 439) had HFrEF. The patients with HFrEF were younger (p < 0.001) and had a history of myocardial infarction more frequently (p < 0.001) compared to HFnrEF, with no other significant differences between the HF groups. The HFrEF patients were more frequently prescribed CV medications than HFnrEF patients. Type 2 Diabetes Mellitus (T2D) was present in 44.7% (n = 1207) of the HF patients. CKD was more frequently present in T2D vs. non-T2D HF patients at every stage (p < 0.001), as well as stroke, peripheral artery disease, and microvascular disease (p < 0.001). Conclusions: In this cohort, considering a contemporary definition, the prevalence of HF was 2.1%. HFrEF accounted for 16.3% of the cases, with a similar clinical−epidemiological profile having been previously reported in the literature. Our study revealed a high prevalence of patients with HFpEF (65.4%), raising awareness for the increasing prevalence of this entity in cardiology practice. These results may guide local and national health policies and strategies for HF diagnosis and management.

Right Ventricular Longitudinal Strain in Patients with Heart Failure

Patients with heart failure (HF) have high morbidity and mortality. Accurate assessment of right ventricular (RV) function has important prognostic significance in patients with HF. However, conventional echocardiographic parameters of RV function have limitations in RV assessments due to the complex geometry of right ventricle. In recent years, speckle tracking echocardiography (STE) has been developed as promising imaging technique to accurately evaluate RV function. RV longitudinal strain (RVLS) using STE, as a sensitive index for RV function evaluation, displays the powerfully prognostic value in patients with HF. Therefore, the aim of the present review was to summarize the utility of RVLS in patients with HF.

Current state of cardiac rehabilitation in Portugal: Results of the 2019 national survey

INTRODUCTION

Cardiac rehabilitation (CR) programs have a central role in cardiovascular medicine, encompassing a comprehensive framework able to holistically address various facets of cardiovascular disease. However, several obstacles to their optimal application have been reported. Over the years, the Portuguese Society of Cardiology has periodically conducted a national survey on the state of CR in Portugal.

OBJECTIVES

This study reports the results of the 2019 survey on CR.

METHODS

In December 2019 a voluntary questionnaire was sent to centers offering CR programs, consisting of several items concerning this intervention.

RESULTS

In 2019, 25 centers provided structured CR programs. A total of 2182 patients underwent phase II programs, representing an increase of 13% from the previous survey. Of these, 67.2% were referred due to ischemic heart disease, and 14.5% due to heart failure. Acute coronary syndromes (ACS) comprised 49.3% of referrals, leading to an estimated 9.3% CR coverage. A total of 606 patients participated in phase III programs (a decrease of 37%). Drop-out rates ranged from 0-68%; 91% of centers presented drop-out rates <25%.

CONCLUSION

The present survey shows an increase in the number of centers and patients undergoing phase II CR, and an increase in the estimated CR coverage after ACS. Despite this, the level of increase means that overall patient representation remained below the optimal range, while the data also showed a decrease in the number of patients in phase III programs. These findings reinforce the importance of optimization of CR entry and maintenance, in order to improve the uptake of this pivotal intervention.

Cost-effectiveness of cardio-oncology clinical assessment for prevention of chemotherapy-induced cardiotoxicity

INTRODUCTION

Cancer chemotherapy increases the risk of heart failure. This cost-effectiveness study analyzes cardio-oncology imaging assessment of left ventricular ejection fraction (LVEF) using a Portuguese healthcare payer perspective and a five-year time horizon.

METHODS

Two cardioprotective strategies were assessed: universal cardioprotection (UCP) for all patients and cardioprotection initiated on diagnosis of LVEF-defined cardiotoxicity (EF-CTX). A Markov model, informed by the retrospective clinical course of breast cancer patients followed in a Portuguese public hospital, was developed to assess the cost-effectiveness of LVEF cardio-oncology imaging assessment. Data on transition probabilities, costs and utilities were retrieved from both the retrospective data and published literature to assess the cost-effectiveness of LVEF echocardiographic assessment. Costs and utilities of the cardioprotective strategies were assessed over a five-year range, using probabilistic sensitivity analyses.

RESULTS

In the reference case of a 63-year-old breast cancer patient treated with cardioprotection initiated on diagnosis of EF-CTX, the five-year time horizon (4.22 QALYs and €2594 cost over five years) dominated UCP (3.42 QALYS and €3758 cost over five years). Under a time horizon of five years at a willingness-to-pay threshold of €22 986, over 65.7% of simulations provided additional QALYs. Monte Carlo simulation of the Markov model had no effect on the model's conclusions.

CONCLUSION

In the Portuguese public healthcare system and under specific hypotheses, from a healthcare payer perspective, EF-CTX-guided cardioprotection for patients at risk of chemotherapy-related cardiotoxicity provides more QALYs at lower cost than UCP.

Cost-effectiveness of cardio-oncology clinical assessment for prevention of chemotherapy-induced cardiotoxicity

INTRODUCTION

Cancer chemotherapy increases the risk of heart failure. This cost-effectiveness study analyzes cardio-oncology imaging assessment of left ventricular ejection fraction (LVEF) using a Portuguese healthcare payer perspective and a five-year time horizon.

METHODS

Two cardioprotective strategies were assessed: universal cardioprotection (UCP) for all patients and cardioprotection initiated on diagnosis of LVEF-defined cardiotoxicity (EF-CTX). A Markov model, informed by the retrospective clinical course of breast cancer patients followed in a Portuguese public hospital, was developed to assess the cost-effectiveness of LVEF cardio-oncology imaging assessment. Data on transition probabilities, costs and utilities were retrieved from both the retrospective data and published literature to assess the cost-effectiveness of LVEF echocardiographic assessment. Costs and utilities of the cardioprotective strategies were assessed over a five-year range, using probabilistic sensitivity analyses.

RESULTS

In the reference case of a 63-year-old breast cancer patient treated with cardioprotection initiated on diagnosis of EF-CTX, the five-year time horizon (4.22 QALYs and €2594 cost over five years) dominated UCP (3.42 QALYS and €3758 cost over five years). Under a time horizon of five years at a willingness-to-pay threshold of €22 986, over 65.7% of simulations provided additional QALYs. Monte Carlo simulation of the Markov model had no effect on the model's conclusions.

CONCLUSION

In the Portuguese public healthcare system and under specific hypotheses, from a healthcare payer perspective, EF-CTX-guided cardioprotection for patients at risk of chemotherapy-related cardiotoxicity provides more QALYs at lower cost than UCP.

Consensus document on chronic coronary syndrome assessment and risk stratification in Portugal: A position paper statement from the [Portuguese Society of Cardiology's] Working Groups on Nuclear Cardiology, Magnetic Resonance and Cardiac Computed Tomography, Echocardiography, and Exercise Physiology and Cardiac Rehabilitation

Despite constant medical evolution, the reimbursement policy of Portuguese National Health Service (NHS) for the study and risk stratification of coronary heart disease has remained unchanged for several decades. Lack of adjustment to contemporary clinical practice has long been evident. However, the recent publication of the European Guidelines for diagnosis and treatment of chronic coronary syndromes further highlighted this gap and the urgent need for a change. Prompted by these Guidelines, the Working Group on Nuclear Cardiology, Cardiac Magnetic Resonance and Cardiac CT, the Working Group on Echocardiography and the Working Group on Stress Pathophysiology and Cardiac Rehabilitation of the Portuguese Society of Cardiology, began a process of joint reflection on the current limitations and how these recommendations could be applied in Portugal. To this end, the authors suggest that the new imaging methods (stress echocardiogram, cardiac computed tomography and cardiac magnetic resonance), should be added to exercise treadmill stress test and myocardial perfusion scintigraphy in the available exam portfolio within the Portuguese NHS. This change would allow full adoption of European guidelines and a better use of tests, according to clinical context, availability and local specificities. The adoption of clinical guidance standards, based on these assumptions, would translate into a qualitative improvement in the management of these patients and would promote an effective use of the available resources, with potential health and financial gains.

The burden of heart failure in North America and Western Europe

Background: We depict the burden of heart failure (HF) in North America (NA) and Western Europe (WE), using a cyclical flow diagram of patients from diagnosis/hospitalization until treatment, stabilization and decompensation/death. Materials & methods: We obtained data on HF hospitalizations, prevalence, severity and treatment from national databases and primary/secondary research. Results: In 2020, we estimate 3.6 and 5.2 million HF hospitalizations, and 7.6 and 8.7 million diagnosed prevalent chronic HF (CHF) cases in NA and WE, respectively. All hospitalized HF and 86-88% of prevalent cases are drug-treated. The most widely prescribed drugs for CHF in NA and WE are β-blockers and loop diuretics, respectively. Conclusion: The high burden of HF in NA and WE calls for greater efforts to prevent ischemic heart disease.

Sodium-Glucose Co-transporter 2 Inhibitors in the Failing Heart: a Growing Potential

Sodium-glucose co-transporter 2 inhibitors (SGLT2i) are a new drug class designed to treat patients with type 2 diabetes (T2D). However, cardiovascular outcome trials showed that SGLT2i also offer protection against heart failure (HF)-related events and cardiovascular mortality. These benefits appear to be independent of glycaemic control and have recently been demonstrated in the HF population with reduced ejection fraction (HFrEF), with or without T2D. This comprehensive, evidence-based review focuses on the published studies concerning HF outcomes with SGLT2i, discussing issues that may underlie the different results, along with the impact of these new drugs in clinical practice. The potential translational mechanisms behind SGLT2i cardio-renal benefits and the information that ongoing studies may add to the already existing body of evidence are also reviewed. Finally, we focus on practical management issues regarding SGLT2i use in association with other T2D and HFrEF common pharmacological therapies. Safety considerations are also highlighted. Considering the paradigm shift in T2D management, from a focus on glycaemic control to a broader approach on cardiovascular protection and event reduction, including the potential for wide SGLT2i implementation in HF patients, with or without T2D, we are facing a promising time for major changes in the global management of cardiovascular disease.

Hyperkalemia and management of renin-angiotensin-aldosterone system inhibitors in chronic heart failure with reduced ejection fraction: A systematic review

INTRODUCTION AND OBJECTIVES

Renin-angiotensin-aldosterone system inhibitors (RAASi) are the cornerstone of treatment of heart failure with reduced ejection fraction (HFrEF). RAASi optimization in real-life care is challenged by hyperkalemia, a potentially fatal adverse event, which can necessitate downtitration or discontinuation of RAASi and negatively impact survival in HFrEF. The literature on this problem is sparse. We performed a systematic review of studies on HFrEF to investigate the prevalence, incidence, and risk factors of hyperkalemia, RAASi prescription rates, frequency of RAASi downtitration or discontinuation due to hyperkalemia, and the potential negative effect of the latter on prognosis.

METHODS

We conducted a MEDLINE (PubMed) search including observational and interventional studies published between January 1987 and May 2018.

RESULTS

A total of 30 observational and 18 interventional studies were included in the review. The incidence of hyperkalemia reported was between 0% and 63% in observational studies and was between 0% and 30% in clinical trials. Risk factors for hyperkalemia included RAASi prescription, older age, diabetes, and chronic kidney disease. In real-life studies, RAASi were downtitrated or discontinued in 3-22% of HFrEF patients; hyperkalemia was the reported cause in 5% of cases. No reports were found on the impact on prognosis of RAASi downtitration or discontinuation due to hyperkalemia.

CONCLUSIONS

Hyperkalemia and RAASi downtitration or discontinuation are frequent, particularly in real-life HFrEF studies. Further research is needed to clarify the role of RAASi downtitration or discontinuation due to hyperkalemia and to assess its long-term prognostic impact in HFrEF patients.

Heart failure units: State of the art in disease management

The prevalence of heart failure has increased over the past decades and is a major social and economic burden on healthcare services. Patient quality of life is severely impaired and heart failure is one of the main causes of death in Portugal. The functional organization of multidisciplinary teams engaged in the treatment of these patients is essential to improve health care provision and outcomes, specifically reducing mortality, hospital admissions, and improving quality of life. We describe current approaches to heart failure management and discuss the organization of heart failure units and cooperation among these units and also with other healthcare professionals.

The historical evolution of knowledge of the involvement of neurohormonal systems in the pathophysiology and treatment of heart failure

Our knowledge of the pathophysiology of heart failure (HF) underwent profound changes during the 1980s. Once thought to be of exclusively structural origin, HF began to be seen as the consequence of hormonal imbalance. A number of seminal studies were published in that decade focusing on the impact of neurohormonal activation in HF. Presently, eight neurohormonal systems are known to have a key role in HF development: four stimulate vasoconstriction and sodium/water retention (the sympathetic nervous system, the renin-angiotensin-aldosterone system [RAAS], endothelin, and the vasopressin-arginine system), while the other four stimulate vasodilation and natriuresis (the prostaglandin system, nitric oxide, the dopaminergic system, and the natriuretic peptide system [NPS]). These systems are strongly interconnected and are subject to intricate regulation, functioning together in a delicate homeostasis. Disruption of this homeostasis is characteristic of HF. This review explores the historical development of knowledge on the impact of the neurohormonal systems on HF pathophysiology, from the first studies to current understanding. In addition, the therapeutic potential of each of these systems is discussed, and currently used neurohormonal antagonists are characterized. Special emphasis is given to the latest drug approved for use in HF with reduced ejection fraction, sacubitril/valsartan. This drug combines two different molecules, acting on two different systems (RAAS and NPS) simultaneously.

Real-world analysis of acute decompensated heart failure outcomes in Portugal

Aims

In Portugal, in the last 5 years, no study has published recent data regarding outcomes of patients with acute decompensated heart failure (ADHF). We aimed to determine the characteristics and outcomes of a large contemporaneous Portuguese cohort of ADHF patients admitted to our emergency department (ED).

Methods and results

We conducted a retrospective, study of all 1024 patients admitted to our ED with a discharge diagnosis of ADHF from November 2016 to December 2017. Baseline clinical data and outcomes {in‐hospital, 30 day, and follow‐up all‐cause mortality, and readmissions; median follow‐up, 5 months; interquartile range [(IQR), 3–11 months]} were determined. Mean age was 78 ± 10 years, and 53% were male; of the 1024 patients, 554 (54%) were hospitalized. The median hospitalization length was 9 (IQR, 5–15) days, and in‐hospital mortality was 12.7%. Hospitalized patients were predominantly men (56% vs. 47%; P < 0.001), younger (77 ± 9 vs. 79 ± 11 years; P = 0.002) and had higher creatinine values and B‐type natriuretic peptide values (P < 0.001) than discharged patients. Patients with prior hospitalization had lower 30 day readmission rate (8% vs. 14%; P = 0.01), same overall readmission rate (30% vs. 32%), and higher 30 day (13% vs. 5%; P < 0.001) and overall mortality rates (28% vs. 15%; P < 0.001).

Conclusions

Approximately half of the patients admitted to the ED were hospitalized. Of these, only 8% were readmitted in the ED within 30 days. The clinical and analytical status in the ED are important predictors of hospitalization.

Protocol-based follow-up program for heart failure patients: Impact on prognosis and quality of life

INTRODUCTION

Heart failure is associated with high rates of readmission and mortality, and there is a need for measures to improve outcomes. This study aims to assess the impact of the implementation of a protocol-based follow-up program for heart failure patients on readmission and mortality rates and quality of life.

METHODS

A quasi-experimental study was performed, with a prospective registry of 50 consecutive patients discharged after hospitalization for acute heart failure. The study group was followed by a cardiologist at days 7-10 and the first, third, sixth and 12th month after discharge, with predefined procedures. The control group consisted of patients hospitalized for heart failure prior to implementation of the program and followed on a routine basis.

RESULTS

No significant differences were observed between the two groups regarding mean age (67.1±11.2 vs. 65.8±13.4 years, p=0.5), NYHA functional class (p=0.37), or median left ventricular ejection fraction (27% [19.8-35.3] vs. 29% [23.5-40]; p=0.23) at discharge. Mean follow-up after discharge was similar (11±5.3 vs. 10.9±5.5 months, p=0.81). The protocol-based follow-up program was associated with a significant reduction in all-cause readmission (26% vs. 60%, p=0.003), heart failure readmission (16% vs. 36%, p=0.032), and mortality (4% vs. 20%, p=0.044). In the study group there was a significant improvement in all quality of life measures (p<0.001).

CONCLUSION

A protocol-based follow-up program for patients with heart failure led to a significant reduction in readmission and mortality rates, and was associated with better quality of life.

Neurohormonal modulation: The new paradigm of pharmacological treatment of heart failure

The current paradigm of medical therapy for heart failure with reduced ejection fraction (HFrEF) is triple neurohormonal blockade with an angiotensin-converting enzyme inhibitor (ACEI), a beta-blocker (BB) and a mineralocorticoid receptor antagonist (MRA). However, three-year mortality remains over 30%. Stimulation of counter-regulatory systems in addition to neurohormonal blockade constitutes a new paradigm, termed neurohormonal modulation. Sacubitril/valsartan is the first element of this new strategy. PARADIGM-HF was the largest randomized clinical trial conducted in HFrEF. It included 8442 patients and compared the efficacy and safety of sacubitril/valsartan versus enalapril. The primary endpoint was the composite of cardiovascular mortality and hospitalization due to HF, which occurred in 914 (21.8%) patients receiving sacubitril/valsartan and in 1117 (26.5%) patients receiving enalapril (HR 0.8, 95% CI 0.73-0.87, p=0.0000002; NNT 21). Sacubitril/valsartan reduced both primary endpoint components, as well as sudden cardiac death, death due to worsening HF, and death from all causes. Patients on sacubitril/valsartan reported less frequent deterioration of HF and of quality of life, and discontinued study medication less frequently because of an adverse event. PARADIGM-HF demonstrated the superiority of sacubitril/valsartan over enalapril, with a 20% greater impact on cardiovascular mortality compared to ACEIs. Accordingly, in 2016, the European (ESC) and American (ACC/AHA/HFSA) cardiology societies simultaneously issued a class I recommendation for the replacement of ACEIs by sacubitril/valsartan in patients resembling PARADIGM-HF trial participants.

The current and future burden of heart failure in Portugal

Aims

Heart failure (HF) is a clinical syndrome with significant social and economic burden. We aimed to estimate the burden of HF in mainland Portugal over a 22‐year time horizon, between 2014 and 2036.

Methods and results

Heart failure burden was measured in disability‐adjusted life years (DALYs), resulting from the sum of years of life lost (YLL) due to premature death and years lost due to disability (YLD). YLL were estimated based on the Portuguese mortality rates reported by the European Detailed Mortality Database. For YLD, disease duration and the overall incidence were estimated using an epidemiological model developed by the World Health Organization (DISMOD II). Disability weights were retrieved from published literature. The impact of ageing was estimated with a shift‐share analysis using official demographic projections. In 2014, 4688 deaths were attributed to HF, corresponding to 4.7% of the total deaths in mainland Portugal. DALYs totalled 21 162, 53.9% due to premature death (YLL: 11 398) and 46.1% due to disability (YLD: 9765). Considering only population ageing over a 22‐year horizon, the deaths and burden of HF are expected to increase by 73.0% and 27.9%, respectively, reaching 8112 deaths and 27 059 DALYs lost due to HF in 2036. DALY's growth is mainly driven by the increase of YLL, whose contribution to overall burden will increase to 62.0%.

Conclusions

Heart failure is an emerging and growing health problem where significant health gains may be obtained. The projected significant increase of HF burden highlights the need to set HF as a priority for healthcare system.