Heart failure in numbers: Estimates for the 21st century in Portugal. / Insuficiência cardíaca em números: estimativas para o século XXI em Portugal.

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

Atrial fibrillation and thromboembolic risk: what is the extent of adherence to guidelines in clinical practice?

BACKGROUND: Atrial fibrillation (AF) is the most common cardiac rhythm disorder in clinical practice, with a growing prevalence in recent decades. Through the use of thromboembolic risk scores it is possible to adjust thromboprophylaxis to individual risk. The aim of this study was to evaluate the conformity of antithrombotic therapy prescribed at hospital discharge with the guidelines in patients with AF and its influence on long-term morbidity and mortality. METHODS: We performed a retrospective analysis, based on medical records and phone interview, of consecutive patients admitted to an internal medicine department over a one-year period with a diagnosis of AF or atrial flutter--ICD-9-CM 427.31/32. We determined individual thromboembolic risk in accordance with the ACC/AHA/ESC risk categories, and assessed conformity of antithrombotic therapy with the guidelines. Independent predictors of long-term (378 +/- 241 days) mortality and mortality or readmission were identified by multivariate analysis. RESULTS: The study population consisted of 174 patients with a diagnosis of AF, 59.8% (104) female, mean age 77 +/- 10 years. Hypertension (65.7%) and heart failure (61.3%) were the most prevalent comorbidities. Most patients (82.7%) were stratified as high thromboembolic risk and the remainder as moderate risk. The antithrombotic therapy prescribed at hospital discharge was documented in 155 patients, 126 (81.3%) with high thromboembolic risk. Of the latter group of patients, oral anticoagulation (OAC) was prescribed in 65 (51.6%) and proposed but contraindicated in 24 (19.0%). In patients with moderate thromboembolic risk, therapeutic options were divided between OAC (69.0%), antiplatelet therapy (17.2%) and no thromboprophylaxis (13.8%). Overall there was discordance between the therapy instituted and the guidelines in 25.8% of patients. Age 85 years or over was the only independent predictor of death (HR 1.92; 95% CI 0.94-3.91), while OAC (HR 0.43; 95% CI 0.27-0.70) and male gender (HR 0.58; 95% CI 0.36-0.94) were independent protective factors against death or hospital readmission. CONCLUSIONS: In this study, patients admitted with AF were mainly elderly, women and with high thromboembolic risk. The prescription rate of OAC in patients at high risk was lower than recommended in the guidelines, which were not followed in a quarter of patients. The main therapeutic option in cases of moderate risk was OAC. OAC use was the only modifiable factor able to improve prognosis of patients with AF, and it is thus crucial to ensure adherence to the guidelines in daily clinical practice.

[Histiocytic necrotizing lymphadenitis: (Kukuchi-Fujimoto disease): a diagnostic challenge]. / Dilemas de diagnóstico de linfadenite necrotizante (doença de Kikuchi-Fujimoto).

Kikuchi-Fujimoto disease, also called Histiocytic necrotizing lymphadentis, is a rare, benign and self-limited disease, with unknown etiology, that affects mainly young women, and is characterized by adenopathy (usually localized in the cervical region) and fever. Diagnosis is based on histopathological findings in ganglionar tissue obtained in excisional biopsy, which allows, in most cases, the differential diagnosis with other similar clinical conditions, but which have a completely different clinical evolution and therapeutic needs. We report a case of a twenty four year old woman with persistent cervical lymphadenopathy, in which histopathological examination followed by immunohistochemical analysis of ganglionar tissue revealed to be Kikuchi-Fujimoto disease.

[Clinical predictors of infectious pulmonary tuberculosis.]. / Indicadores clínicos de infecciosidade na tuberculose pulmonar.

INTRODUCTION: The immediate identification of infectious tuberculosis and implementation of effective isolation measures, are a priority of the national policies for disease control. OBJECTIVES: To identify clinical predictor's factors related with sputum smear-positive, in patients with pulmonary tuberculosis diagnosis. POPULATION AND METHODS: This was a retrospective study involving 289 patients admitted consecutively with the diagnosis of tuberculosis (ICD-9-CM: 010-018) through the emergency department of a Central Hospital. The study was conducted from January 1999 to December 2005. RESULTS: 216 patients (74.7%) were identified with pulmonary tuberculosis: mean age 40.3 (SD 16.1); 77.8% males. Of these 179 (82%) were smear-positive and 157 (54.5%) had human immunodeficiency virus (HIV) co-infection. Of the 37 patients with sputum smearnegative 18 (48.6%) had culture positive. The clinical factors that were better related with sputum smear-positive were: cough with sputum (p = 0.031) and classic chest radiograph patterns, parenchymal consolidation (p < 0.001) and cavitation (p = 0.002). HIV co-infection wasn't associated with a higher risk of infectious tuberculosis. CONCLUSIONS: Respiratory symptoms and classic patterns on chest radiograph, were clinical factors better related with a higher probability of sputum smear-positive. In these patients it is a good clinical practice to propose immediate isolation measures even before the results of sputum smear.

Blood pressure in young adults.

INTRODUCTION: Hypertension (HT) is a major cardiovascular risk factor. Elevated blood pressure (BP) in childhood predisposes to HT in adulthood. Epidemiological studies in young age-groups are scarce. The aim of this study was to determine the prevalence of HT in a population of university students aged between 18 and 25 years; to analyze the profile of HT in the presence of other risk factors; and to alert patients and physicians to the need to assess and control cardiovascular risk factors in young adults. METHODS: We performed an observational, descriptive and cross-sectional study of a convenience sample of 402 university students, born between June 1, 1980 and May 24, 1988. Through a self-administered questionnaire and biometric measurements we recorded the following variables: BP, age, gender, smoking, regular medication, family history of HT, stress and body mass index. BP was determined by the mean of two measurements and classified according to the European Society of Cardiology guidelines. RESULTS: In the study population 229 (57%) individuals were female and 173 (42%) male, mean age 21 +/- 2 years. The prevalence of HT was 24.9% (20.4% with isolated systolic HT) and 27.4% had high normal BP. Among males 43.9% had HT, while among females only 10.5% were hypertensive. There was a high prevalence of HT in overweight (50.8%) and obese (50.0%) subjects. Among those exposed to stress, 27.2% had isolated systolic HT. A trend for HT was also found in young women taking oral contraceptives and in students with hypertensive first-degree relatives. CONCLUSIONS: The prevalence of HT and high normal BP in the study population of young adults was high. There was a statistically significant correlation between HT and male gender, HT and overweight and between isolated systolic HT and stress, confirming the existence of clusters of cardiovascular risk factors. Patients and their primary care physicians were alerted to the importance of assessing and controlling overall cardiovascular risk in young subjects.

Portuguese study of familial dilated cardiomyopathy: the FATIMA study.

Dilated cardiomyopathy (DCM) is a myocardial disease, characterized by ventricular dilatation and impaired systolic function, that in more than 30% of cases has a familial or genetic origin. Given its age-dependent penetrance, DCM frequently manifests in adults by signs or symptoms of heart failure, arrhythmias or sudden death. The predominant mode of inheritance is autosomal dominant, and in these cases mutations are identified in genes coding for cytoskeletal, sarcomeric or nuclear envelope proteins. To date, most studies aimed at molecular diagnosis of DCM have been in selected families, or in larger groups of patients, but screening for mutations in a limited number of genes. Consequently, the epidemiology of mutations in familial DCM remains unknown. There is thus a need for multicenter studies, involving screening for a wide range of mutations in several families and in cases of idiopathic DCM. The present article describes the methodology of a multicenter study, aimed at clinical and molecular characterization of familial DCM patients in the Portuguese population.

Validity of a discharge diagnosis of heart failure: implications of misdiagnosing.

Heart failure (HF) costs are largely due to hospitalization. The validity of a death/discharge diagnosis of HF (DDHF) is largely unknown. The authors assessed the validity of DDHF and the impact of misdiagnosing. The case notes of patients consecutively admitted to a medical department between January and June 2001 were reviewed. Cases with DDHF or cardiovascular diseases, potential precursors of HF (PPHF), were included. The diagnosis of HF (European Society of Cardiology guidelines) was classified as definite, possible, or miscoded. Of the 1038 patients admitted, 234 were enrolled: 157 with DDHF and 77 with PPHF. One hundred eighty patients had a definite diagnosis of HF. Of the 157 diagnoses coded as definite HF, 130 were correct, 21 had possible HF, and 6 were miscoded. Of the 77 patients classified as having PPHF, 38 had definite HF. The accuracy of the DDHF diagnosis was 72.2%: 21.1% were underdiagnosed and 8.3% overdiagnosed. DDHF failed to capture many HF admissions and therefore alone underestimates the prevalence, burden, and costs of the syndrome.

Post-percutaneous coronary angioplasty atheroembolization--a feared iatrogenic complication.

Atheroembolic disease is a rarely recognized clinical entity. The growing use of antiplatelet and thrombolytic therapy and of invasive cardiovascular procedures in acute coronary syndromes has nevertheless transformed this feared iatrogenic complication into an increasingly frequent diagnosis. The authors review this entity through the case of a 71-year-old man who, fifteen days after undergoing thrombolysis for acute myocardial infarction with ST-segment elevation, followed by elective percutaneous coronary revascularization under triple antiplatelet therapy, came to the emergency department with a clinical setting of mental confusion, gastrointestinal bleeding, oliguria and cutaneous eruptions on the lower limbs; laboratory tests revealed severe azotemia and hyperkalemia. With a diagnostic hypothesis of systemic atheroembolization, a cutaneous lesion biopsy was performed, which confirmed the diagnosis. Supportive treatment led to neurological and cutaneous recovery, but the patient developed chronic renal failure. The pathophysiology, forms of presentation, treatment and prognosis of atheroembolic disease are discussed, highlighting the importance of a high degree of clinical suspicion for diagnosis.

Metformin-induced lactic acidosis: a case series.

INTRODUCTION: Unlike other agents used in the treatment of type 2 diabetes mellitus, metformin has been shown to reduce mortality in obese patients. It is therefore being increasingly used in higher doses. The major concern of many physicians is a possible risk of lactic acidosis. The reported frequency of metformin related lactic acidosis is 0.05 per 1000 patient-years; some authors advocate that this rate is equal in those patients not taking metformin. CASE PRESENTATION: We present two case reports of metformin-associated lactic acidosis. The first case is a 77 year old female with a past medical history of hypertension and type 2 diabetes mellitus who had recently been prescribed metformin (3 g/day), perindopril and acetylsalicylic acid. She was admitted to the emergency department two weeks later with abdominal pain and psychomotor agitation. Physical examination revealed only signs of poor perfusion. Laboratory evaluation revealed hyperkalemia, elevated creatinine and blood urea nitrogen and mild leukocytosis. Arterial blood gases showed severe lactic acidemia. She was admitted to the intensive care unit. Vasopressor and ventilatory support was initiated and continuous venovenous hemodiafiltration was instituted. Twenty-four hours later, full clinical recovery was observed, with return to a normal serum lactate level. The patient was discharged from the intensive care unit on the sixth day. The second patient is a 69 year old male with a past medical history of hypertension, type 2 diabetes mellitus and ischemic heart disease who was on metformin (4 g/day), glycazide, acetylsalicylic acid and isosorbide dinitrate. He was admitted to the emergency department in shock with extreme bradycardia. Initial evaluation revealed severe lactic acidosis and elevated creatinine and urea. The patient was admitted to the Intensive Care Unit and commenced on continuous venovenous hemodiafiltration in addition to other supportive measures. A progressive recovery was observed and he was discharged from the intensive care unit on the seventh day. CONCLUSION: We present two case reports of severe lactic acidosis most probably associated with high doses of metformin in patients with no known contraindications for metformin prescription. In both patients no other condition was identified to cause such severe lactic acidosis. Although controversial, lactic acidosis should be considered in patients taking metformin.

Translating guidelines into clinical practice: benefits of an acute heart failure unit .

UNLABELLED: Heart failure (HF) is a very prevalent condition, with high mortality, morbidity and costs, despite the development of effective drug therapy. Many patients still do not have access to appropriate treatment. Heart failure clinics have shown success in improving delivery of appropriate HF management, helping to reduce morbidity and mortality and costs. AIMS: To compare the quality of diagnosis and drug therapy at discharge in an unselected population of patients admitted to a medical ward of an urban central teaching hospital before and after the creation of a heart failure unit (HFU) and to evaluate its impact on long-term mortality and morbidity from all causes and from HF. METHODS: We compared a population of 153 patients, aged 75 +/- 12.8 years, 50.3% male, with a diagnosis of HF according to the guidelines of the European Society of Cardiology, NYHA classes II-IV (74% III or IV), admitted consecutively to a medical ward (MW) before the creation of an HFU (Group 1), with a population of 82 patients, aged 73 +/- 12.4 years, 62.2% male, admitted consecutively to the HFU for acute decompensated HF (Group 2). The prescription of diuretics, spironolactone, angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, angiotensin receptor antagonists (ARAs) and warfarin in the two groups at discharge was analyzed. The endpoints of the study were: in-hospital mortality (IM), mortality and hospitalization due to all causes (P1), mortality and hospitalization due to HF (P2), all-cause mortality (P3), and mortality due to HF (P4). The follow-up duration was 18 months. RESULTS: The two populations were not statistically different in gender, age or type of HF. HF diagnosis was correct in 67.7% of cases in Group 1, vs. 86% in Group 2. The increase in the prescription of beta-blockers in Group 2 compared with Group 1 was highly significant (4.9% vs. 36.0%, p = 0.000 in all-cause HF patients and 28.9% vs. 56.8%, p = 0.000, in HF due to systolic dysfunction), as was that of warfarin (16.7% vs. 32.6%, p = 0.003 in all-cause HF and 17.6% vs. 44.4%, p = 0.001, in HF due to systolic dysfunction). IM in the MW vs. HFU was 7.7% vs. 8.5% (p = 0.42). The probabilities for the different end-points in MW/HFU at 6, 12 and 18 months were: P1: 55/35% (p = 0.013), 68/46% (p = 0.0005) and 73/51% (p = 0.0004); P2: 26/19% (p = 0.1), 34/20% (p = 0.008) and 39/23% (p = 0.004); P3: 25.5/21% (p = 0.22), 31/30% (p = 0.44) and 38/35% (p = 0.32); P4: 16/19% (p = 0.28), 23/20% (p = 0.3) and 27/33% (p = 0.25). CONCLUSIONS: These results are in agreement with reported morbidity and mortality from the syndrome after hospitalization. There is a tendency for better outcome in all the studied endpoints among the population treated in the HFU, despite greater severity of the disease, compared to those treated in the MW. A statistically significant improvement was found in the composite endpoints of mortality and hospitalization from all causes and due to HF, at 12 and 18 months. The results of the study indicate that the HFU had a better performance in reducing morbidity than mortality compared to the MW. As hospitalization accounts for 60% of HF costs, HFUs are expected to be cost effective.

Systemic markers of the redox balance and apolipoprotein E polymorphism in atherosclerosis: the relevance for an integrated study.

Prospective studies have demonstrated that an imbalance between oxidative damage and antioxidative protection can play a role in the development and progression of atherosclerosis. Also, genotypes with the apolipoprotein E epsilon4 allele have been associated with an increase risk for this pathology. Based on this knowledge, the aim of this study was to evaluate indicators of the redox balance, trace elements, and apolipoprotein E allelic profile in subjects from the Lisbon population with clinically stable atherosclerosis, at risk for atherosclerotic events, and in healthy subjects for comparison. The activities of superoxide dismutase in erythrocytes and glutathione peroxidase in whole blood, plasma total thiols, and serum ceruloplasmin were kept unchanged among the three groups. Serum alpha- tocopherol was increased in atherosclerotic patients. Total malondialdehyde in serum and protein carbonyls in plasma, which are indicators of lipid and protein oxidative damage, respectively, reached their highest values in risk subjects. The concentrations of potassium and calcium, in plasma and in blood cells, were slightly elevated in patients and might reflect an electrolytic imbalance. Regarding the apolipoprotein E polymorphism, atherosclerotic patients had an increased incidence of the high-risk genotypes for atherogenesis (epsilon3/epsilon4 and epsilon4/epsilon4). A multivariate model applied to the general population using most of the parameters clearly separated the three groups at study (i.e., the healthy group from the steady-state group of risk disease and from the atherosclerotic one). As shown by us, the usefulness of biochemical and complementary genetic markers is warranted for a better knowledge on atherosclerosis molecular basis.

Acutely decompensated heart failure: characteristics of hospitalized patients and opportunities to improve their care.

UNLABELLED: Heart failure (HF) remains a major public health problem in western countries, despite the enormous progress in its diagnosis and treatment. Acute and chronic decompensated HF are leading medical causes of hospitalization among people aged over 65 years in European countries, the USA, Australia and New Zealand. However, there have been few studies on acute and chronic decompensated HF and the European Society of Cardiology (ESC) guidelines on this subject have only just been published. AIM: To evaluate the overall prevalence of hospitalization due to HF according to its subtypes, comorbidities, and decompensating factors, in the Medical Department of a central teaching hospital in an urban area. METHODS: We performed a retrospective observational study of patients admitted consecutively to the Medical Department via the emergency room between January and June 2001. Discharge casenotes on 1038 admissions were reviewed. Those with a diagnosis of HF or cardiovascular conditions associated with or precursors of HF were analyzed. Cases with a final diagnosis of HF according to the criteria of the ESC guidelines were included in the study. We evaluated the overall prevalence of HF and subtypes of cardiac dysfunction, etiological risk factors, patients' demographic characteristics, decompensating factors, comorbidity, mean length of hospital stay, and in-hospital mortality rate. RESULTS: We identified 180 patients with HF (17.4%), mean age 74.6 +/- 14; 87 were male (48%), aged 73.7 +/- 14.2, and 93 female (52%), aged 75.6 +/- 14. Left ventricular systolic dysfunction (LVSD) was present in 42.2% of cases, preserved left ventricular systolic function in 32.6%, and valvular heart disease in 10.6%. Hypertension and coronary artery disease were the main etiological risk factors (62.2% and 42.8% respectively). Atrial fibrillation was recorded in 43.4% of the patients, diabetes was diagnosed in 21.6%, and anemia and chronic obstructive pulmonary disease in about one third. Infection, predominantly respiratory, was the main factor triggering decompensation, followed by uncontrolled hypertension and supraventricular tachyarrhythmia. At admission, 42.2% of the patients were in NYHA class III and 44.8% in NYHA class IV. HF patients had a mean hospital stay of 13.8 days, slightly shorter than the mean overall stay of patients admitted to the Medical Department in the same period (14.5 days). In-hospital mortality for HF patients was 7.7%, with HF being the first cause of admission to the Medical Department, followed by stroke (10.6%). CONCLUSIONS: This study confirms the high prevalence of acute or chronic decompensated HF in patients hospitalized in the Medical Department of a central teaching hospital in an urban area. The patients were mainly elderly, of both genders, with a slightly higher proportion of HF due to LVSD. Most patients were in NYHA classes III and IV. Mean hospital stay was no longer than that of all patients admitted in the same period. The in-hospital mortality rate was low. The age-group affected and the high prevalence of multiple comorbidities emphasize the need to establish HF clinics with multidisciplinary teams to manage these patients, and health authorities must be made aware of the burden of this syndrome.

Epidemiology of heart failure in primary care in Madeira: the EPICA-RAM study.

UNLABELLED: Chronic heart failure (CHF) is a serious public health problem all over the world. CHF has a high prevalence, affecting mainly the elderly, and causes severe disability and social and economic costs. AIM: To estimate the prevalence of chronic heart failure in the Autonomous Region of Madeira in 2001. METHODS: This was a community-based epidemiological survey involving subjects attending primary care centers selected by a combined two-stage sampling and stratifying procedure. General practitioners (GPs) randomly selected in proportion to the population of each municipality evaluated subjects aged over 25 years attending primary care centers, recruited consecutively and stratified by age. CHF cases were identified according to the Guidelines of the European Society of Cardiology for CHF diagnosis. RESULTS: Six hundred and eighty-six eligible subjects were evaluated by 30 GPs; 60 patients with CHF were identified. The overall prevalence and 95 % CI of CHF in Madeira was 4.69 % (2.91 % to 6.46 %), 3.53 % in males (0.81 % to 6.26 %), and 5.58 % in females (3.37 % to 7.79 %). CHF prevalence increases with age: 1.24 % (0.00 % to 2.96 %) in the 25 to 49-year-old group, 6.17% (1.31 to 11.03 %) in those aged 50 to 59 years, 7.62 % (0.75 to 14.49 %) in those aged 60 to 69 years, 13.32 % (7.99 % to 14.49 %) in the 70 to 79-year-old group, and 14.34 % in the group over 80 years old (7.59 % to 21.09 %). The prevalence of CHF due to systolic dysfunction was 0.76 % and 2.74 % with normal systolic function. CONCLUSIONS: The overall prevalence of CHF in Madeira was similar to that of mainland Portugal, and slightly higher than that of other European studies. Overall CHF prevalence increases sharply with age. The prevalence of CHF with preserved systolic ventricular function was similar to that reported by other recent European studies. The prevalence of CHF due to systolic dysfunction was much lower. The differences found may correspond to differences in methodology rather than actual differences in the population. CHF with left ventricular systolic dysfunction seems to be rare in primary care in Madeira. This may be related to the different public health organization in Madeira, and deserves further evaluation.

[Epidemiology of heart failure in mainland Portugal: new data from the EPICA study]. / Epidemiologia da insuficiência cardíaca em Portugal Continental: novos dados do estudo EPICA.

Heart failure (HF) is common, costly, disabling and lethal, and can be prevented. The progression of overt HF (CHF) can be slowed by correct management including precise diagnosis and appropriate therapy. Patients with CHF can be misdiagnosed, mainly in primary care, where patients are actually less symptomatic than those seen in hospitals. Accurate diagnosis requires objective evidence of cardiac dysfunction at rest by imaging techniques, according to the European Society of Cardiology (ESC) Guidelines. The EPICA Project (EPidemiologia da Insuficiência Cardiaca e Aprendizagem) was one of the first European studies designed to evaluate the prevalence of CHF according to those criteria. The estimated overall prevalence of CHF in Portugal was 4.36% in adults over 25 years. 1058 individuals were identified by the Boston questionnaire as possible or probable CHF cases; only 551 had objective evidence of cardiac dysfunction at rest by echocardiography. 264 patients in sinus rhythm had a Boston score > 3 and no echocardiographic abnormalities. These patients were predominantly older obese women; coronary artery disease was less prevalent than in patients with proved CHF. The ECG was normal in 40.9%, versus 20% in CHF patients. About one half of these patients were prescribed ACE inhibitors and diuretics; 17% were prescribed digoxin. According to these EPICA data concerning CHF, older obese women are more frequently misdiagnosed and incorrectly medicated.

The diagnosis of heart failure in primary care: value of symptoms and signs.

BACKGROUND: The value of symptoms and signs in the diagnosis of CHF has rarely been tested in large numbers of patients in the community. The aim of this study was to evaluate the importance of symptoms, signs, and past medical history in the diagnosis of CHF in primary care. METHODS: Data on a sample of Portuguese men and women attending 365 primary care centres for any condition other than the treatment of acute infection, metabolic conditions or pregnancy were collected. All subjects who scored three or more points in the sum of categories one and two of the Boston questionnaire (history and physical examination) and those being treated for heart failure with loop or thiazide diuretics were considered to have possible heart failure and referred for further assessment including a resting echocardiogram. The sensitivity, specificity, positive predictive value, negative predictive value and likelihood ratio (LR) for the diagnosis of heart failure were calculated. RESULTS: A total of 5434 subjects were identified, of whom 1058 fulfilled the criteria for further assessment; 551 subjects had cardiac dysfunction at rest, of which 35.5% were in NYHA class I and 4.9% in class IV. Prior use of digoxin (LR 24.9) and/or diuretics (LR 10.6), a history of coronary artery disease (LR 7.1) or of pulmonary oedema (LR 54.2), were associated with a greater likelihood of having heart failure. Amongst current symptoms, a history of paroxysmal nocturnal dyspnoea (LR 35.5), orthopnea (LR 39.1) and breathlessness when walking on the flat (LR 25.8) were associated with a diagnosis of heart failure. However, these symptoms were not frequent amongst patients with heart failure within this population (sensitivity <36%). Jugular pressure > 6 cm with hepatic enlargement, and oedema of the lower limbs (LR 130.3), a ventricular gallop (LR 30.0), a heart rate above 110 bpm (LR 26.7), and rales at pulmonary auscultation (LR 23.3) were all associated with a diagnosis of heart failure, but were infrequent findings in patients with heart failure (sensitivity <10%). CONCLUSIONS: Symptoms and signs, and clinical history had limited value in diagnosing heart failure when used alone. The signs and symptoms that best predicted a diagnosis of heart failure were those associated with more severe disease. If investigation is limited to patients with more definite symptoms and signs of heart failure, fewer than 50% of cases will be identified and a large number of patients with mild symptoms will be missed.

Aetiology, comorbidity and drug therapy of chronic heart failure in the real world: the EPICA substudy.

BACKGROUND: Chronic heart failure (CHF) is common and is frequently managed by primary care physicians (PCPs). Despite the European Society of Cardiology (ESC) Guidelines, standard treatments for CHF are frequently underutilised, particularly in primary care. AIM: To evaluate current drug therapy for CHF in adults with HF diagnosed according to ESC guidelines in the context of the EPICA study. Aetiological features and therapy relevant comorbidities were also analysed. METHODS: EPICA was a community-based epidemiological study conducted in mainland Portugal. The study involved 365 primary care physicians, who evaluated 6300 primary care attendees aged over 25 years. CHF was diagnosed by clinical and echocardiography criteria according to ESC guidelines. RESULTS: Total of 551 cases of CHF were identified, with a mean age of 65+/-9 years. The estimated overall prevalence of CHF in the Portuguese population was 4.4%; 1.3% with and 1.7% without left ventricular systolic dysfunction (LVSD). There are 6,280,792 people aged >25 years in Portugal, which extrapolates to 261,400 cases of heart failure. About 80% of patients had a history of hypertension, 39% had a history of coronary artery disease and 15% had atrial fibrillation. Only 58% of patients were on angiotensin-converting enzyme (ACE) inhibitors and 7% on beta-blockers. The type of ventricular dysfunction, age and presence of renal failure had little effect on prescription rates. Diuretics were prescribed in 78%. Thiazides were used more frequently in those with preserved systolic function and frusemide in those with left ventricular systolic dysfunction. Digoxin was prescribed more often to patients with than without left ventricular systolic dysfunction (34% vs. 17%; p=0.02). Long-acting nitrates were prescribed to 20% and amiodarone to 8% of patients. CONCLUSION: The EPICA study, as in other studies in primary care in Europe, particularly the IMPROVEMENT study, suggests that greater efforts are required to improve training of primary care teams in the management of CHF.

The value of the electrocardiogram and chest X-ray for confirming or refuting a suspected diagnosis of heart failure in the community.

BACKGROUND: There is a common assumption that a normal ECG or a normal heart size on chest X-ray virtually rules out a diagnosis of heart failure. AIMS: To assess the value of the electrocardiogram and chest X-ray in identifying patients with chronic heart failure in the community. METHODS AND RESULTS: This study was a secondary analysis of data prospectively collected at the time of patient's enrollment in the EPICA study, an epidemiological study of the prevalence of heart failure in Portugal. A total of 6300 subjects were clinically evaluated. Patients who presented with symptoms or signs of heart failure, and/or were receiving diuretics for chronic heart failure (CHF) had a chest X-ray, ECG, and echocardiogram. The diagnosis of heart failure was confirmed in 551 cases. Patients with right atrial enlargement, atrial flutter, atrial fibrillation, 2nd degree-Mobitz I atrioventricular block, 1st degree atrioventricular block, left bundle branch block, lung interstitial oedema, and bilateral pleural effusion were more likely to be diagnosed with heart failure. For the diagnosis of heart failure, in the Portuguese population aged over 25 years, an abnormal electrocardiogram had an estimated sensitivity of 81%, and negative predictive value of 75%; an abnormal chest X-ray had an estimated sensitivity of 57%, and negative predictive value of 83%. Twenty five percent of patients with CHF had a normal ECG or chest X-ray. CONCLUSION: Our results show that electrocardiographic and roentgenographic features are not sufficient to allow heart failure to be reliably predicted in the community and support the recommendation that all patients with suspected heart failure should undergo echocardiography.

Evaluation of the performance and concordance of clinical questionnaires for the diagnosis of heart failure in primary care.

AIM: To validate and estimate the performance statistics and concordance of seven clinical questionnaires for the diagnosis of chronic heart failure (HF). METHODS: Community-based epidemiological survey of patients aged >25 years attending a random sample of primary health care centers in Portugal. Heart failure was identified according to the Guidelines of the European Society of Cardiology (ESC). RESULTS: A total of 5434 subjects evaluated by 365 investigators were eligible for analysis, 551 of which had criteria for heart failure. Overall, the questionnaires had high specificity, usually above 90%, but low sensitivity, providing an increase in the likelihood of heart failure from 4.3% pre-test to 25-35% post-test in most cases. The Göteborg questionnaire was the most balanced regarding sensitivity (84%) and specificity (81%) but this may reflect its use of prescription of digoxin or diuretics as diagnostic criteria for diagnosis. The Walma, Framingham and NHANES-I questionnaires performed similarly (Sensitivity: 63%, Specificity: 93%), while the Boston and the Gheorghiade questionnaires had a somewhat lower sensitivity (55%). Concordance was good between the Boston, Framingham, Gheorghiade, NHANES-I and Walma questionnaires. CONCLUSIONS: This study evaluated seven clinical questionnaires for the diagnosis of heart failure in the community. Their low sensitivity impairs their usefulness as diagnostic instruments, but their high specificity makes them useful for the identification of patients with fluid retention and/or exercise intolerance from non-cardiac causes.

Comparative value of BNP and NT-proBNP in diagnosis of heart failure.

UNLABELLED: Heart failure (HF) remains a major diagnostic challenge. Brain natriuretic peptide (BNP) and the N-terminal portion of proBNP (NT-proBNP) have emerged as excellent diagnostic biohumoral indicators in cardiac disease. It is not clear which of the two is superior as a diagnostic marker in HF. OBJECTIVE: To compare the ability of BNP and NT-proBNP to distinguish subjects with HF from healthy volunteers, as well as to differentiate between HF with left ventricular (LV) systolic dysfunction (SD) and HF with preserved systolic function (PSF). METHODS: We measured plasma BNP (Shionogi, Osaka) and NT-proBNP (ELECSYS) in 21 healthy individuals (control group [CG]), 11 men, 10 women, mean age 54.4 +/- 11.6 years, with normal ECG and chest X-ray, and in 86 HF patients (HFG), 48 men, 38 women, mean age 71 +/- 11 years, in NYHA II-IV, fulfilling the European Society of Cardiology guidelines: 60 had HF with SD (SDG), ejection fraction (EF) < 40%, and 26 had HF and PSF (PFG), EF > 40%, increased LV mass index and/or dilated left atrium. BNP and NT-proBNP mean and median values were compared and the correlation between the 2 peptides was established. For each peptide sensitivity (sens), specificity (spec) 93.7%, positive predictive value (PPV) 75.5% and negative predictive value (NPV) were calculated. Areas under the ROC curve (AUC) were determined for each group vs. CG and for SDG vs. PFG. RESULTS: Levels of BNP and NT-proBNP were significantly higher in HF patients, particularly in the SDG, than in healthy subjects. There was reasonable agreement between BNP and NT-proBNP. For BNP, AUC were: HFG vs. CG: 97.7-98.0%; SDG vs. CG: 98.6-99.1%; PFG vs. CG: 95.1-95.9%; PFG vs. SDG: 69.7-70.9%; and for NT-proBNP: HFG vs. CG: 99.2-99.3%; SDG vs. CG: 99.6-99.7%; PFG vs. CG: 98.3-98.5%; PFG vs. SDG: 63.3-63.6%. For a cut-off of 32 pg/ml, BNP has 91.7% sens, 93.7% spec, 75.5% PPV and 98.3% NPV. A NT-proBNP cut-off of 126 pg/ml has 96.3% sens, 98.8% spec, 94.3% PPV and 99.3% NPV. CONCLUSIONS: Both peptides had an excellent ability to distinguish HF from non-HF subjects. NT-proBNP was more sensitive and specific. Nevertheless, neither peptide could differentiate between the SDG and the PFG by itself. NT-proBNP is a simple, highly effective diagnostic test for HF. A favorable impact on management and costs is expected from implementation of this diagnostic test in clinical practice.