Evaluation of the Impact to the Treatment of Heart Failure in the Brazilian Public Health System

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.


Introduction
Heart failure (HF) is a major public health problem that affects about 23 million people worldwide and five million in the United States 1 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 blood 2 .
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 them 3 .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 65 5 , and the Framingham study found that the incidence of HF, in turn, doubles every decade of life 6 .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 HF 2 .

ABREVIATURAS E ACRÔNIMOS
• EF -ejection fraction • HF -heart failure • HM -Hospital de Messejana Systolic and diastolic ventricular dysfunction are the two most important mechanisms for reducing cardiac output and establishment of HF 2 .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 PREVEND 7 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 dysfunction 7 .
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 dysfunction 6,8,9 .
Predisposing factors for HF have been identified in several studies, especially coronary artery disease, smoking, hypertension, obesity, diabetes mellitus and valvular heart disease 10 .
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 causes 11,12 .
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 syndrome 13 .
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 contributing to readmissions and consequent increase in mortality [14][15][16][17] .
The Framingham study found that, after 1990, the annual mortality from HF was 28.0% for men and 24.0% for women.Mortality due to HF in five years was 59.0% for men and 45.0% for women 14,16,18,19 .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 heart 20,21 .Ventricular tachycardia degenerating into ventricular fibrillation is the most common cause of sudden death in patients with HF 22 .
The treatment of HF has been the subject of numerous consensus, protocols and guidelines, with specific approaches for acute and chronic cases 23 .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 mortality 13,[24][25][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 antagonists 13,23 .
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.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.
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.
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%.
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.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).

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 sex 28,29 .
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 syndrome 23 .
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 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 HF 13,26 .
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 therapy 13,23 .
In this study, the records showed that the drug therapy was appropriately administered to most patients with HF, according to the ACCF/AHA 24 , 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 Barroso 31 , 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 patients of Medicare-USA 32 , contrasting with 11.0% mortality after 30 days reported by another study 33 ; the Framingham study showed a 12.0% reduction trend in mortality due to HF per decade of life after 1980 34 .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 21 st 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.

Table 1 General characteristics of the patients studied
SD -standard deviationSilva et al.Evaluation of the Treatment of Heart Failure Int J Cardiovasc Sci.2015;28(2):130-138 Original Manuscript