The purpose of the Brazilian Society of Cardiology (SBC) is to expand and disseminate
knowledge on Cardiovascular Science and to make each cardiologist aware of the
activities intended to promote cardiovascular health in Brazilian society. Since its
foundation, SBC has been stimulating research and dissemination, among civil society,
of
epidemiological and preventive matters related to the treatment of cardiovascular
diseases, including heart failure (HF). HF has been identified as a cardiovascular
epidemic throughout the world and involves important aspects on morbidity, mortality
and
healthcare costs, being little recognized among individuals, members of our society,
healthcare managers and policy makers. The increasing prevalence of HF is due to
population aging and the growth of risk factors, such as obesity, systemic arterial
hypertension and diabetes mellitus, as well as increased survival of patients with
heart
diseases, such as congenital heart disease and ischemic heart disease. Worldwide,
about
26 million adults have HF and forecasts indicate that the prevalence tends to increase
by 25% by 2030.
1
Within the scenario, it should be underscored that HF with preserved ejection fraction
(HFPEF) needs greater recognition and prevention strategies by general practitioners,
geriatricians and cardiologists.
2
The
syndrome presents asymptomatic stages and a symptomatic form, and preventive and
therapeutic measures are able to reduce the progression of the disease and
morbimortality. Outbreaks of acute HF and decompensation promote recurrence in emergency
rooms and hospital admissions that promote worsening of the condition, where the outcome
can be abrupt due to pump failure or sudden death.
3
In this decade, initiatives in different countries, led by
cardiology associations and societies, have promoted activities to warn the population
and health professionals regarding early detection, complementary tests and access
to
medications and treatment based on scientific evidence.
Under the leadership of the Department of Heart Failure of the Brazilian Society of
Cardiology (DEIC/SBC), Brazil is engaged in promoting activities related to this topic,
by creating the awareness day, to be celebrated each year on July 9th, the
data of birth of genius and pioneer cardiovascular translational scientist Carlos
Justiniano Ribeiro das Chagas. This year, two dates are very remarkable: 140 years
of
the birth of professor and researcher Carlos Chagas and 110 years of the discovery
of
Chagas’ disease. A unique fact in the history of Medicine, in which a single researcher
describes the vector, the etiological agent, identifies the hosts and attempts to
identify the clinical forms of the disease.
4
The theme of Chagas’ disease, in our country, remains contemporary,
not only in the search for new treatments,
5
vaccines and new forms of contamination, such as the oral route
described in the north, northeast and south regions, involving sugarcane and
açaí, reported this year in the Brazilian Archives of
Cardiology,
6
but also in the
current outbreak of acute Chagas’ disease in Pernambuco, still in the process of
clarification. Tribute has been paid to scientist Carlos Chagas in Brazil in several
ways (Figure 1), but we have identified that his
contribution to cardiology and HF was definitive and important, representing his
remarkable name for this noble cause in our country.
Figure 1
A) The ten thousand Brazilian cruzados note in honor of Carlos Chagas – “The
notable physician in his laboratory” – launched in 1988. B) Stamp
commemorating the 35th Brazilian Conference on Cardiology in honor of Carlos
Chagas, 1979. C) Commemorative Stamp of the National Health Day – Chagas’
Disease, 1980.
With continental dimensions, our country has a great diversity of lifestyle,
environmental, socioeconomic and cultural risk factors, as well as the composition
of
its health system (access, organization of the healthcare network, financing,
availability of technological resources and professionals). IC clinics that can offer
multiprofessional care have been shown to reduce admissions and improve quality of
life.
Cardiac rehabilitation has proven effectiveness, but it is not yet available, causing
the low inclusion of people in these programs. Different factors may explain the
variability of the number of hospital admissions, early retirement for HF and use
of
resources - heart transplantation, surgery, cardiac catheterization, pacemaker
implantation, defibrillators and healthcare costs. According to Araujo et al.,
7
the direct cost of treatment is
represented mainly by hospitalization and costs with medication. However, indirect
costs
represent economic impacts similar to direct costs. A recent study estimates that
about
BRL 22.1 billion/US$ 6.8 billion were spent on the treatment of HF in our country
in
2015 alone,
8
and could represent 68% of
hospitalization costs, as seen in the USA and Europe, due to costly diagnostic
techniques, high cost of medications, interventions and devices. Therefore, reducing
hospital admissions is critical for reducing costs, in addition to the physical and
psychological limitations that can be worsened in these patients, particularly
depressive symptoms and anxiety. The increasing prevalence of hospital admissions,
estimated in some centers at up to 25%, and high hospital morbidity and mortality
rates,
especially in the presence of comorbidities, such as renal failure, have been documented
in different studies.
9,10
Private sector data are beginning to be described and
published as those present at the Observatory of the National Association of Private
Hospitals (ANAHP) on patients admitted due to HF in a group of hospitals with
accreditation and protocols to serve this population. Data from the 2019 Observatory
reveal,
11
in 2017 and 2018,
respectively, a median of stay of 7.56 and 6.72 (SD = 3.72), inpatient mortality of
7.49% and 5.26%, rate of use of angiotensin converting enzyme (ACE) inhibitors or
angiotensin receptor blockers (ARA) on discharge of 89.43% and 88.41% (SD = 17.40%)
and
rate of use of betablockers at discharge of eligible patients of 93.29% and 94.29%
(SD =
10.09%).
Being aware of this variability in healthcare and outcomes of HF is important for
us to
help improve the quality of care in our country. Through the BREATHE registry, DEIC
has
studied patients from different regions of the country and verified the high in-hospital
mortality among those admitted with acute HF associated with low rate of prescription
of
evidence-based medicines in Brazil.
12
Fonseca et al.
13
have found that
through the demographic changes observed over the years in continental Portugal and
the
clinical practices currently employed, in about 40 years, the country will have half
a
million patients undergoing treatment for HF, highlighting the extreme need for raising
people’s awareness, improving reference levels and healthcare so that the burden of
the
syndrome in the country may have its representativity diminished. They also stress
the
importance of optimizing healthcare strategies, organizing essential healthcare
services, promoting adjustments while respecting regional characteristics, by avoiding
a
single model of work, reiterating the need for organized discussions at all levels
of
healthcare to the population.
14
Corroborating this need for adjusting and regionalizing healthcare, Kaufman et
al.
15
argue that, considering
the last 12 years of HF in Brazil, the Southeast region presented the highest number
of
hospital admissions, accounting for 41.4% of hospital admissions according to DATASUS
data. In the characterization of this population in South America, Brazil contributes
with most of the studies, accounting for 64% of the production of published data,
being
the only one to present its incidence in a population study.
16
DEIC/SBC has continuously used its Acute and Chronic Heart Failure Guideline published
in
2018 to ensure the best scientific evidence available on diagnosis and
treatment.
3
Regarding the role
of diagnosis and beginning of treatment, many patients are still diagnosed during
their
first admission for acute HF. This demonstrates the need for greater investment in
the
continuing education of general practitioners, clinicians and cardiologists working
at
family clinics, basic health units and practices, and in the multidisciplinary and
organized healthcare, in order to coordinate the line of care, palliative care
protocols, in short, medical care based on HF teams. In the experience of Germany,
63.2%
of the new cases were identified in a doctor’s office and 94% of diagnosed patients
received their first prescription from the general practitioner. Cases of HF in
hospitalized patients, where previous diagnosis was given by a non-specialist in 70.7%,
reaffirm the strategy of investing in mechanisms of recognition of the disease in
this
group of professionals.
17
In our
country, we do not have a healthcare process based on the full care of patients in
a
standardized way, which leads to delayed diagnosis in many patients, without the
recognition of signs and symptoms by individuals and caregivers. This said, the process
of education, recognition of the main symptoms and treatment are imperative needs,
and
initiatives that can promote knowledge about HF are fundamental for improving the
quality of care. Besides those, access to complementary tests that demonstrate the
objective presence of HF, such as the biomarkers brain natriuretic peptide (BNP) and
N-terminal prohormone of brain natriuretic peptide (NT pro-BNP), and imaging scans
for
the correct handling of these patients.
It is necessary to emphasize the importance of obtaining population registries to
draw up
a global picture of HF. China, Malaysia and South Africa, involved in the International
Congestive Heart Failure (Inter-CHF) study, show that although socioeconomic
similarities are distinct in etiology, comorbidities, sociodemographic characteristics
and outcomes,
18
some comorbidities,
such as diabetes mellitus, atrial fibrillation and chronic kidney disease, have been
shown to be independent factors associated with hospital admissions and mortality
in
some samples. Hospital admissions and visits to the emergency room were also shown
to be
associated with outcomes in several studies.
19
Despite these well-established comorbidities correlated to
outcomes, we found a group whose role is not yet properly characterized, such as sleep
apnea, iron deficiency, sarcopenia and chronic obstructive pulmonary disease. Further
studies regarding the contribution of these comorbidities in mortality still need
to be
developed.
20
Learning about
disparate socioeconomic conditions that modify the incidence of HF in different regions
in the same country can also be derived from population registries. Even in health
systems such as that of the UK, it can be seen that social inequalities interfere
with
accessibility and lead to a consequent increase in cases of the syndrome.
21
As for mortality, using hospital
records and death certificates for the mapping out HF, we have observed that, so it
can
be better characterized, we need to validate a standardized registration methodology
using more accurate statistical analyses. The inconsistencies between hospital records
and reports of cause of death are presented as a window of opportunity for the
implementation of studies to improve quantification in all regions of Brazil.
22
Along with the Brazilian Heart Failure
Network (REBRIC), we intend to mobilize all the instances involved in healthcare,
disseminating ideas and sharing knowledge to improve healthcare.
23
HF specialists and cardiologists have the important challenge, at the present time,
of
organizing the health assistance process in the coordination of lines and resources,
aiming at expanding the connection with general practitioners, emergency surgeons,
geriatricians and hospitalists, promoting the improvement of clinical outcomes and
the
patient’s journey. The project that we call the HF Map will be one of the priorities
of
the Department of Heart Failure of the Brazilian Society of Cardiology for 2020-2021,
following the consolidated model of comprehensive epistemological assessment of HF
figures in our country, tested by the European Society of Cardiology (ESC) and by
the
European Society of Heart Failure (ESHF/ESC).
24
This will be done through a digital platform that will collect
data from different regions in order to quantify and make available the figures of
this
epidemic in our country. This platform will be implemented in 2020 and will include
national data from the public and private sectors, from regulated organizations and
scientific publications, which will be evaluated by data scientists, cardiovascular
epidemiologists and clinical and population health researchers. Within this plan,
the
1st Registry of Cardiomyopathies and Myocarditis in Children and
Adolescents will be carried out in collaboration with the Group of Studies in
Cardiomyopathies (GEMIC/SBC), aiming at mapping out and describing this population
to
contribute with better proposals of continuing medical education, clinical diagnostic
criteria and creation of specialized centers of treatment and care.
In short, the construction of a day of awareness on HF (Figure 2), on Carlos Chagas’
date of birth, aims at raising the awareness
for healthcare professionals, patients, relatives and society in general; and the
decision makers in health, who can make decisions and take actions that can influence
the evolution of this important cardiovascular epidemic in Brazil. This is one of
DEIC’s
commitments, which is in lined with the mission of SBC, and supported by the National
Academy of Medicine.
Figure 2
This is the logo of the heart failure awareness day campaign promoted by
DEIC/SBC, supported by the National Academy of Medicine.