1. health and fitness
2. disease

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Internacional Journal of Cardiovascular Sciences. 2015;28(2):130-138
ORIGINAL MANUSCRIPT
Evaluation of the Impact to the Treatment of Heart Failure in the
Brazilian Public Health System
Frederico Augusto de Lima e Silva1, Guilherme Emilio Ferreira2,
Ezequiel Aguiar Parente2, Eduardo Cesar Rios Neto2
Hospital de Messejana Dr. Carlos Alberto Studart Gomes – Serviço de Cardiologia – Fortaleza, CE – Brazil
Centro Universitário Christus – Curso de graduação em Medicina - Fortaleza, CE – Brazil
1
2
Resumo
Background: Heart failure (HF) is a worldwide health problem with the prospect of further increasing its prevalence
due to population growth and increased life expectancy. The clinical treatment of patients with HF is the use of
drugs, devices and procedures that improve cardiac performance, relieve symptoms and prolong survival.
Objective: To evaluate the impact of treatment of heart failure in Hospital de Messejana (HM), Fortaleza, CE,
Brazil.
Methods: This is an observational, retrospective and quantitative study. In this study, 635 adult patients admitted
in the Cardiac Units of HM from January 2011 to July 2013 were evaluated through the analysis of medical records.
The study evaluated aspects related to mortality rates, treatment effectiveness and the number of readmissions.
It also investigated the incidence of hospital infections and the percentage of patients whose treatment was heart
transplantation.
Results: Concerning the clinical treatment, 88.3% used anticoagulants, 80.8% used diuretics, 74.2% used
beta-blockers, 48.7% used angiotensin-converting enzyme inhibitors and 19.25% used angiotensin receptor blocker.
About the surgery, 11% had valvuloplasty or valve replacement, 9.3% had heart transplantation, 2.2% had
pacemaker implant and 4.7%, coronary artery bypass grafting surgery.
Conclusion: Patients treated with HF in HM received the classic therapy recommended, including the use of
surgical devices and procedures such as heart transplantation and had a satisfactory outcome in most cases,
despite a high rate of in-hospital mortality.
Keywords: Treatment intention analysis; Survival analysis; Heart failure; Hospital mortality; Hospitalization
Introduction
Heart failure (HF) is a major public health problem that
affects about 23 million people worldwide and five million
in the United States1 alone. This is a complex clinical
syndrome that characterizes the final stage of various heart
diseases. Changes in function or cardiac structure lead to
impairment of ventricular ability to fill or eject blood2.
Data show that, in Brazil, HF is the third leading cause
of hospitalization and the most common reason for
hospitalization among the elderly, and is the most
common cardiovascular disease among them3. According
to Nogueira et al.4, in Brazil there are approximately two
million patients with HF. About 240,000 cases are
diagnosed per year.
Records show that the prevalence of HF increases with
age from the age of 655, and the Framingham study found
that the incidence of HF, in turn, doubles every decade
of life6. Population aging and life extension in patients
with heart disease by modern therapy, which uses
powerful drugs combined with efficient devices, have
increased the incidence of HF2.
Corresponding author: Frederico Augusto de Lima e Silva
Av. Frei Cirilo, 3480 - Messejana - 60840-285 - Fortaleza, CE - Brazil
E-mail: [email protected]
DOI: 10.5935/2359-4802.20150018
Manuscript received on November 20, 2014; approved on March 23, 2015; revised on April 12, 2015.
Int J Cardiovasc Sci. 2015;28(2):130-138
Original Manuscript
Systolic and diastolic ventricular dysfunction are the two
most important mechanisms for reducing cardiac output
and establishment of HF2. However, there is an important
variability among the records of HF due to diastolic
dysfunction defined by a normal left ventricular (LV)
ejection fraction. The PREVEND7 study recently showed
that among 8 592 patients, 4.4% develop HF in 11 years
of follow-up, with 34.0% for diastolic dysfunction and
66.0% for systolic dysfunction7.
The risk of developing HF at age 40 is 1:5 individuals,
regardless of sex, while mortality, around 16.4:1 000, still
shows a tendency to increase and low survival rates after
hospitalization, which is 30% lower in patients with
diastolic dysfunction6,8,9.
Predisposing factors for HF have been identified in
several studies, especially coronary artery disease,
smoking, hypertension, obesity, diabetes mellitus and
valvular heart disease10.
Coronary artery disease, idiopathic dilated
cardiomyopathy, hypertension and valvular disease are
the major causes of heart failure due to systolic
dysfunction. In diastolic dysfunction, hypertension,
coronary artery disease and the restrictive and
hypertrophic cardiomyopathies are the most prevalent
causes11,12.
The diagnostic approach in HF, thoroughly discussed
and guided by a number of guidelines, should include a
detailed medical history, thorough physical examination
and a set of indispensable complementary tests:
electrocardiogram, chest X-ray, blood leukocyte dosages,
hemoglobin, creatinine, glucose, liver and thyroid tests,
pro-BNP dosage, echocardiography (this must be done
in all patients with suspected HF), exercise testing,
cardiac catheterization, cardiovascular magnetic
resonance imaging and endomyocardial biopsy; these
are intended to confirm the diagnosis, determine the
degree of severity and the probable etiology of the
syndrome13.
In the evolution of patients with HF, it is observed that
the need for hospitalization is an important marker of
a bad prognosis, with increased mortality after
hospitalization, especially in the first month after
hospital discharge. Similarly, failure to follow the drug
treatment and diet are the most important factors
Silva et al.
Evaluation of the Treatment of Heart Failure
contributing to readmissions and
consequent increase in mortality14-17.
131
ABREVIATURAS E
ACRÔNIMOS
•EF — ejection fraction
The Framingham study found that, after
1990, the annual mortality from HF was
•HF — heart failure
28.0% for men and 24.0% for women.
• HM — Hospital de Messejana
Mortality due to HF in five years
was 59.0% for men and 45.0% for
women14,16,18,19. The most important causes of death
observed in patients with HF were sudden death or
arrhythmic death, described as death within the first hour
after cardiac arrest in previously stable patients, or
progressive failure of the heart20,21. Ventricular tachycardia
degenerating into ventricular fibrillation is the most
common cause of sudden death in patients with HF22.
The treatment of HF has been the subject of numerous
consensus, protocols and guidelines, with specific
approaches for acute and chronic cases23. All treatment
guidelines state that the main HF treatment objectives
are the clinical improvement of symptoms, reduced risk
of hospitalization, reduction or reversal of impairment
of myocardial function and reduced mortality13,24-26.
The pharmacological treatment protocol of HF in
Hospital de Messejana Dr. Carlos Alberto Studart Gomes,
Fortaleza, CE, Brazil includes several drugs which, in
addition to improving the symptoms, can increase the
survival of patients: diuretics, beta-blockers, angiotensinconverting enzyme inhibitors (ACE), angiotensin II
receptor blockers, hydralazine + nitrates and aldosterone
antagonists13,23.
The high number of patients with HF admitted to HM,
with the most varied etiologies in different functional
classes and several long-term re-admissions encouraged
the performance of this study to analyze the quality of
HF treatment offered by HM.
Methods
This is an observational, retrospective, quantitative study
held at HM, in Fortaleza, CE, in the neighborhood of
Messejana, from August 2013 to July 2014.
From January 2011 to July 2013, 762 patients were
admitted to the Cardiac Units (B, C, G and I) of HM.
However, only 635 adult patients were located and
evaluated through their medical records. The therapeutic
plan adopted for each patient was mainly observed.
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Silva et al.
Evaluation of the Treatment of Heart Failure
Int J Cardiovasc Sci. 2015;28(2):130-138
Original Manuscript
The patients included in the study had been diagnosed
with heart failure, with the following criteria: signs and
symptoms, chest radiography and echocardiography.
In addition, patients with both preserved ejection
fraction (EF) and decreased EF participated in the study.
There was also some required data recorded in the
medical records.
The study excluded the following patients: those with
pacemakers admitted to the HM ICU using mechanical
ventilator, patients under 18 with HF, patients with
clinical picture of cardiogenic shock, post-transplant
patients diagnosed with HF. Regarding readmissions of
patients in this period, only the first visit was used. The
main limitation found by the researchers was to achieve
a statistically significant number of medical records that
contained all the necessary information.
In this study, p values ≤
​​ 0.05 were considered statistically
significant.
The study was approved by the Research Ethics
Committee of Hospital de Messejana Doutor Carlos
Alberto Studart Gomes, under No. 600.762-0, in line with
all the ethical principles set out in Resolution CNS 466/12.
The Researcher’s Instrument of Liability for using
medical records was signed by the researchers, assuring
them that the use of medical records would serve
exclusively for this research project and also on
maintaining the anonymity of the patients involved, in
addition to the Instrument of Bona Fide Custodian signed
by HM medical archive clerk.
Results
Aspects related to mortality rates, treatment effectiveness
and the number of hospital readmissions were firstly
evaluated. Secondly, the incidence of hospital infections
and the percentage of patients whose treatment was heart
transplantation were investigated. Furthermore, there
was a comparison between patients with and without
infection, patients transplanted or not, and the outcome
of patients.
The study included 635 patients: 427 (67.2%) males and
208 (32.8%) females. The age distribution ranged from
18 to 95 years, with mean age of 59.85±16.05 years. The
mean hospital stay time was 4.71±1.76 weeks, ranging
from 1-30 weeks. Regarding the number of readmissions,
a variation of 0-19 was found, averaging 1.08±3.52. The
ejection fraction averaged 40.88± 15.84%, ranging from
8.0-83.0% (Table 1).
The information collected was compiled into a database
managed by the statistical software IBM SPSS Statistics
20 and Microsoft Office 2013 Excel program. Initially, a
standard descriptive statistics was taken: central
tendency calculation and frequency distribution. The
Mann-Whitney test was used to check the association of
the independent variables on the outcomes of the study.
The distribution of the etiology of HF among the patients
studied showed that idiopathic dilated cardiomyopathy
was most prevalent (34.8%), followed by ischemic
cardiomyopathy (32.4%), valvular heart disease (20.3%),
Chagas cardiomyopathy (6.3%), alcoholic cardiomyopathy
(4.3%), hypertrophic cardiomyopathy (1.7%) and
peripartum cardiomyopathy (0.2%) (Table 2).
Table 1
General characteristics of the patients studied
Mean±SD
Minimum-maximum values
59.85±16.05
18-95
Length of stay (weeks)
4.71±1.76
0-19
Readmissions (number)
1.08±3.52
1-30
40.88±15.84
8-83
Age (years)
Ejection fraction (%)
SD — standard deviation
Int J Cardiovasc Sci. 2015;28(2):130-138
Original Manuscript
Silva et al.
Evaluation of the Treatment of Heart Failure
The analysis of predisposing factors for HF showed that
hypertension was the most prevalent (62.4%) followed
by smoking (42.7%), valvular heart disease (35.9%),
diabetes mellitus (33.7%), coronary artery disease (32.8%)
and obesity (8.3%) (Table 2).
Table 2
Etiology, risk factors and tests performed by the patients
studied
%
Etiology
Risk factors
Tests
Idiopathic cardiomyopathy
34.8
Ischemic cardiomyopathy
32.4
Valvular heart disease
20.3
Chagas cardiomyopathy
6.3
Alcoholic cardiomyopathy
4.3
Hypertrophic cardiomyopathy
1.7
Peripartum cardiomyopathy
0.2
Hypertension
62.4
Smoking
42.7
Valve diseases
35.9
Diabetes mellitus
33.7
Coronary artery disease
32.8
Obesity
8.3
In the diagnostic approach of HF, all patients underwent
electrocardiogram and chest X-ray. Echocardiography
was performed in 99.2% of patients, followed by complete
blood count in 98.6%, hemodynamic study in 40.6%,
Holter in 14.8%, pro-BNP dosage in 1.4% and exercise
test in 1.1%. On echocardiogram, there was an average
EF of 40.88±15.84%, ranging from 8 to 83%.
By assessing the physical examination upon admission,
dyspnea was present in 95.6% of patients, being the most
prevalent symptom. Other findings on physical
examination were edema (47.2%), abnormal cardiac
auscultation (47.1%), abnormal breath sounds (43.9%),
jugular venous distension (4.3%) and hepatosplenomegaly
(2.8%).
Electrocardiogram
100.0
Chest X-ray
100.0
Electrocardiogram
99.2
Complete blood count
98.6
Hemodynamic study
40.6
Holter
14.8
Pro-BNP
1.4
Cardiac stress test
1.1
With regard to infection, 37.8% of patients showed some
expression: 69.2% occurred in the respiratory system,
15.0% in the cardiovascular system, 6.7% in the urinary
system, 6.7% in the dermatological system and 2.4% in
the gastrointestinal system. Stratifying patients into two
groups, with and without infection, there was a
significant difference in the length of stay (p < 0.0001),
in which the group with infection took longer to receive
hospital discharge (Table 3).
Concerning the clinical treatment, 88.3% used
anticoagulants, 80.8% used diuretics, 74.2% used betablockers, 48.7% used angiotensin-converting enzyme
inhibitors (ACEI) and 19.25% used angiotensin receptor
blockers (ARB). All patients received low-sodium diet.
Table 3
Characteristics of hospitalized patients stratified by group: with and without infection
With infection
No infection
(n=238)
(n=397)
61.37±16.37
58.93±15.82
0.058
Readmissions (number)
1.15±1.72
1.04±1.74
0.333
Length of stay (weeks)
5.72±3.74
4.10±3.23
< 0.0001
40.09±15.71
41.35±15.92
0.326
Age (years)
Ejection fraction (%)
Values expressed as mean±standard deviation
p
133
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Evaluation of the Treatment of Heart Failure
Int J Cardiovasc Sci. 2015;28(2):130-138
Original Manuscript
Of those using diuretics, 67.8% used loop diuretics, 26.9%
used potassium-sparing diuretics and 5.3% used
thiazides. Of those who used beta-blockers, 80.7% took
carvedilol, 8.9% took metoprolol, 6.3% took atenolol and
4.1% tool propranolol. Regarding percutaneous
treatment, 5.4% underwent transluminal coronary
angioplasty with stenting (Table 4).
Surgical treatment was performed in 33.1% of patients.
Of these, 11% underwent valvuloplasty or valve
replacement, 9.3% had transplantation, 2.2% had
pacemaker implant and 4.7%, coronary artery bypass
grafting surgery. 12.8% had breast implants, 23.3% had
bypass surgery and 63.9% both.
Comparing patients who needed heart transplantation
(Group 1) or not (Group 2), there was a significant difference
in relation to age, length of stay, number of readmissions and
ejection fraction (p < 0.0001). Group 1 showed lower average
age, longer hospital stay, greater number of readmissions
and lower ejection fraction than Group 2 (Table 5).
In this study, the mortality rate was 18.9%. Comparing
patients who had improved outcome (Group 3) with the
group that died (Group 4), there was a significant
difference in relation to the mean ejection fraction
(p=0.001) and the mean number of readmissions
(p=0.03). Group 4 had a higher average of readmissions
and a lower mean ejection fraction than Group 3 (Table 6).
Table 4
Treatments performed in the patients studied
%
Anticoagulant
Low-sodium diet
ARB
ACEI
Clinical treatment
Diuretics
Beta-blocker
Percutaneous
treatment
Coronary artery bypass grafting
Surgical treatment
Yes
88.3
No
11.7
Yes
100.0
Yes
19.5
No
80.5
Yes
48.7
No
51.3
Loop
54.8
K+ sparing diuretics
21.7
Thiazide
4.3
Did not use
19.2
Carvedilol
59.8
Metrapolol
6.6
Atenolol
4.7
Propranolol
3.0
Did not use
25.8
Stent
4.3
Balloon
0.6
Both
0.5
Bypass surgery
1.1
Breast implant
0.6
Both
3.0
Heart transplant
9.3
Valve replacement Valvuloplasty
11.0
ICD
2.2
Other
5.9
ARB — angiotensin receptor blocker; ACEI — angiotensin-converting enzyme inhibitor; ICD — cardioverter
Int J Cardiovasc Sci. 2015;28(2):130-138
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Silva et al.
Evaluation of the Treatment of Heart Failure
Table 5
Characteristics of the patients studied stratified by groups: transplanted and non-transplanted
Transplanted
Non transplanted
(n=59)
(n=576)
48.68±12.95
60.99±15.92
< 0.0001
Readmissions (number)
2.14±3.06
0.97±1.53
< 0.0001
Length of stay (weeks)
7.03±4.89
4.47±2.26
< 0.0001
Ejection fraction (%)
27.92±9.78
42.20±15.75
< 0.0001
Age (years)
p
Values expressed as mean±standard deviation
Table 6
Characteristics of the patients studied stratified by groups: improved evolution and death
Improved evolution
Death
(n=485)
(n=120)
59.44±16.14
61.80±15.2
0.106
Readmissions (number)
1.02±1.81
1.22±1.62
0.030
Length of stay (weeks)
4.61±3.43
5.42±3.88
0.068
41.78±15.78
36.74±15.13
0.001
Age (years)
Ejection fraction (%)
p
Values expressed as mean±standard deviation
Discussion
Because it is a public hospital and a local and regional
reference for the treatment of cardiovascular diseases,
Hospital de Messejana receives a large number of patients
with various cardiovascular system diseases in different
conditions and receiving various treatment regimens in
which most do not have any etiological and/or syndromic
diagnosis. Receiving all of them, diagnosing them
correctly and quickly and initiating appropriate therapy
is a constant challenge on the daily routine of the
Hospital.
In this study, we observed an average age of 59.85 years;
in the study conducted by Stewart et al.27, the average
was 55.0 years, which shows a possible difficulty in
identifying affected patients at the primary care level. In
this study, there was a prevalence of HF increased in men
(67.2%) compared to women (32.8%). Previous
epidemiological studies show, however, that despite a
relative incidence of higher HF among men, about 50.0%
of HF cases are observed in women, mainly due to the
longer life expectancy of the female sex28,29.
The therapeutic approach of HF seeks an accurate
assessment of the etiology, investigation of factors that
contribute to the worsening of clinical symptoms, in
addition to the severity of the syndrome23.
In this sample, the prevailing HF etiology was idiopathic
cardiomyopathy (34.8%), confirming Felker et al.30, whose
study showed a prevalence of 50.0%. The most prevalent
mechanism was systolic dysfunction with 72.0% of cases;
in the PREVEND study, systolic dysfunction (66.0%)7
prevailed. Hypertensive patients and smokers were the
majority of patients with HF, while respiratory infections
were the most prevalent ones.
Correction of systemic factors, treatment of comorbidities,
changes in life style, suspension of drugs that contribute
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Evaluation of the Treatment of Heart Failure
to HF, vaccination against influenza and pneumonia,
treatment of underlying diseases, drug therapy,
hospitalization when necessary, use of devices such as
cardioverter defibrillator (ICD), resynchronization
therapy, ventricular assist devices, coronary angioplasty,
coronary artery bypass grafting and valve replacement,
heart transplant, plus a home support program after
discharge are the required strategies to achieve the best
results in the treatment of patients with HF13,26.
Pharmacological treatment of HF comprises several drugs
that improve symptoms, such as digoxin (recommendation/
level of evidence --R/NE-IIa/B); moreover, they can increase
the survival of patients, such as beta blockers (I A),
ACE inhibitors (I A), angiotensin receptor blockers II (I A),
hydralazine + nitrates (IIa B) and aldosterone antagonists
(I A)13,24. In some cases, we can also observe the need to
use antiarrhythmics, anticoagulants (I A in concomitant
atrial fibrillation) and the treatment of anemia in order to
optimize the therapy13,23.
In this study, the records showed that the drug therapy
was appropriately administered to most patients with
HF, according to the ACCF/AHA24, observing, however,
a high average of readmissions (1.08 weeks), which might
be due to the non-adherence to treatment (medication
changes, poor diet, alcohol consumption or inappropriate
substances), new triggering factors (infection,
uncontrolled type 2 diabetes mellitus, anemia, pregnancy,
electrolyte disorders, thyroid dysfunction) or worsening
of the underlying disease (new ischemic episode,
uncontrolled hypertension, onset of atrial fibrillation,
pulmonary embolism, worsening of secondary mitral
insufficiency)13,23,24.
Invasive treatment, in this sample, was applied to about
40.0% of patients with valve replacement surgery and
heart transplants with greater expression. In relation to
heart transplantation, the higher prevalence in younger
patients (48.68 years on average) should be noted, since
it is an invasive procedure that requires a good clinical
response from the patient. According to Barroso31, heart
transplant indications are for patients with dilated
cardiomyopathies class III/IV from the New York Heart
Association (NYHA), thus showing a more severe clinical
picture of this group of individuals. Therefore, this study
shows this greater severity through the longer
hospitalization time, about seven weeks, due to the
increased number of readmissions (average of 2.14 times)
and low ejection fraction (27.92%).
Mortality from HF remains high among patients who
became symptomatic. However, there are records showing
reduction in in-hospital mortality of 5.1% to 4.2% among
Int J Cardiovasc Sci. 2015;28(2):130-138
Original Manuscript
patients of Medicare-USA 32, contrasting with 11.0%
mortality after 30 days reported by another study33; the
Framingham study showed a 12.0% reduction trend in
mortality due to HF per decade of life after 198034. The
present series showed a mortality rate of 18.9%, considered
high, since the Brazilian studies of Villacorta et al.35 and
Rohde et al.36 showed a mortality rate of 10.6% and 11.0%,
respectively. By analyzing the patients who died, there was
a statistically significant association in the number of
readmissions and ejection fraction. There was a higher
number of admissions as well as lower EF, which is believed
to be due to the greater severity of the underlying disease.
By analyzing the infections in patients, there has been a
greater incidence on those whose age is higher; but not
statistically significant (p > 0.05), as well as a greater
number of hospital admissions and lower ejection
fraction with p = 0.333 and p = 0.326, respectively.
However, there was a positive statistical significance in
the length of stay (p < 0.001), mainly related to
complications arising from the fact that the patient has
to remain in bed rest for a long time, proven by the studies
of Blanes et al.37 and Barretto et al.38.
The limitations of this study relate primarily to data
collection, due to lack of medical records some patients
in hospital during the study period; the lack of patient
data, the lack of an electronic database with all Hospital
admissions and the lack of a functioning protocol in HM
made it difficult to identify diagnostic criteria.
The knowledge of this reality will certainly help improve
and humanize the performance of physicians and the
multidisciplinary team involved, and increase the
awareness of our managers about the need for
administrative strategies to ensure the best treatment for
patients with this disease, which will be the most
important one in the 21st century.
Conclusion
Patients with HF treated in HM received the classical
therapy recommended, including the use of surgical
devices and procedures such as heart transplantation and
had a satisfactory outcome in most cases, despite a high
rate of in-hospital mortality.
Potential Conflicts of Interest
No relevant potential conflicts of interest.
Sources of Funding
This study had no external funding sources.
Academic Association
This study is not associated with any graduate programs.
Int J Cardiovasc Sci. 2015;28(2):130-138
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Evaluation of the Treatment of Heart Failure
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