abchf abchf ABC Heart Fail Cardiomyop ABC Heart Fail Cardiomyop 2764-3107 Sociedade Brasileira de Cardiologia - SBC abchf.20230092 10.36660/abchf.20230092 Review Article How to Change the Medical History of Patients with Heart Failure and Recurrent Hospitalizations? 0000-0002-2612-8040 Andrade Fernanda Almeida Conception and design of the research Acquisition of data Writing of the manuscript and Critical revision of the manuscript for content 1 0009-0002-5042-2968 Monferdini Luana Conception and design of the research Acquisition of data Writing of the manuscript and Critical revision of the manuscript for content 2 3 0000-0001-5982-8847 Vieira Jefferson Luís Conception and design of the research Acquisition of data Writing of the manuscript and Critical revision of the manuscript for content 4 5 Universidade Federal de São Paulo São Paulo SP Brazil Universidade Federal de São Paulo/UNIFESP, São Paulo, SP – Brazil Hospital e Maternidade Celso Pierro PUC Campinas Campinas SP Brazil Hospital e Maternidade Celso Pierro – PUC Campinas, Campinas, SP – Brazil Hospital das Clínicas Botucatu Unesp Botucatu SP Brazil Hospital das Clínicas Botucatu – Unesp, Botucatu, SP – Brazil Hospital de Messejana Dr. Carlos Alberto Studart Fortaleza CE Brazil Hospital de Messejana Dr. Carlos Alberto Studart, Fortaleza, CE – Brazil Universidade Federal do Ceará Fortaleza CE Brazil Universidade Federal do Ceará, Fortaleza, CE – Brazil Mailing Address: Jefferson Luís Vieira • Hospital de Messejana - Unidade de Transplante e Insuficiência Cardíaca - Av. Frei Cirilo, 3480. Postal Code 60864-190, Fortaleza, CE - Brazil E-mail: jefvieira@yahoo.com.br, jefvieira31@gmail.com

Potential conflict of interest

Dr. Jefferson Vieira reports fee for serving on the adjudication committee of clinical events from the Hospital Israelita Albert Einstein ARO and fees for conferences from AstraZeneca, Boehringer-Ingelheim & Eli Lilly, Novartis, Bayer, Pfizer, Merck and Viatris.

 31 12 2023 2023 3 2 e20230092 24 11 2023 16 12 2023 16 12 2023 This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract

Heart failure (HF) is a progressive condition, characterized by variable periods of symptomatic stability frequently interrupted by episodes of A worsening condition. These moments of clinical deterioration have been recognized as a distinct phase in the course of HF and indicate a considerably worse prognosis. Preventing readmissions of patients with HF is a growing priority for medical providers, researchers, and healthcare managers. Although evidence-based therapies for treating patients with HF have increased, consistent implementation of these therapies and the development of new strategies to prevent readmissions continue to be areas for continued improvement. In this review, we will discuss some proposals and challenges associated with reducing readmissions due to HF.

 Heart Failure Diuretics Hospitalization Mortality Introduction

Heart failure (HF) is a complex and progressive condition, characterized by variable periods of symptomatic stability, usually interrupted by episodes of decompensation, after which patients rarely return to their initial quality of life (Figure 1). Even during the phase of apparent clinical stability, there is still a significant residual risk of clinical deterioration associated with recurrent readmissions and new cardiovascular events that contribute to the worsening of the disease.1,2 This course becomes progressively worse until reaching final pump failure and death, or, in rare cases, heart transplantation.

Journey and risk profiles of patients with heart failure. The diagnosis of HF carries a significant intrinsic clinical risk (baseline risk), which can be reduced through the use of guideline-based medical therapy. Even during the phase of apparent clinical stability, there is still a residual risk of clinical deterioration that may be associated with recurrent readmissions and new cardiovascular events (Worsening Heart Failure). Arrows represent directionality between risk profiles – patients in the worsening phase may respond to optimized therapy and return to a residual risk state or may progress to the advanced risk stage. ICD: implantable cardioverter defibrillator; HF: heart failure; CRT: cardiac resynchronization therapy. Adapted from Greene et al.<xref ref-type="bibr" rid="B1"><sup>1</sup></xref>

According to the largest database of payment sources for hospital admissions in the United States, the Nationwide Inpatient Sample (NIS), hospitalizations for HF in the country increased from 1,060,540 in 2008 to 1,270,360 in 2018.3 However, it has become increasingly evident that not all patients with decompensated HF are hospitalized, as many of these patients are treated on an outpatient basis.4,5 In fact, a significant proportion of patients hospitalized for acutely decompensated HF have recurrent unplanned visits to the doctor’s office or to the emergency room before hospital admission. In 2019, more than 1,500,000 emergency consultations with a diagnosis of decompensated HF were recorded in the United States alone.3 These moments of clinical deterioration have been characterized as a distinct phase in the course of patients with HF, called Worsening Heart Failure (WHF) (Figure 1).1,6 WHF is defined by the progression of signs and symptoms of HF in patients with chronic ventricular dysfunction despite optimized medical therapy, and involves the need for hospitalization or therapeutic scheduling on an outpatient basis, generally with increased diuretic therapy. This is because the main pathophysiological mechanism of acute HF decompensation is congestion, not low output. According to data from the Brazilian registry of hospitalizations for HF, BREATHE extension, the predominant clinical-hemodynamic profile in admissions for HF in the country between 2011 and 2018 was hot-humid (71.7%), while a small number of patients (12.9%) showed no signs of congestion or poor perfusion;7 among more than 3,000 evaluated individuals, the main cause of decompensation was low adherence to drug therapy, in 28% of the patients, followed by infections (21%) and arrhythmia (14%). The diversity of readmission triggers highlights the importance of comprehensive care to prevent complications from secondary conditions and patient-specific risk factors (Table 1).

– Causes for worsening heart failure
Low adherence to drug therapy Failure to follow medication prescriptions as instructed by a healthcare professional can lead to worsening symptoms and a decline in heart function.
Increased salt and water intake Consuming too much salt (sodium) can cause fluid retention, which can worsen heart failure symptoms. Not monitoring your fluid intake and exceeding recommended limits can also be problematic.
Cardiac events Myocardial infarction or other cardiac events can further weaken the heart muscle, leading to aggravated heart failure.
Infections Infections, especially respiratory infections, can overload the heart and worsen symptoms.
Arrhythmias Irregular heart rhythms can reduce the heart's pumping efficiency and contribute to aggravated heart failure.
Lifestyle Smoking, excessive alcohol consumption, and lack of physical activity can worsen heart failure.
Other medical conditions Conditions such as high blood pressure, diabetes, and kidney disease can worsen heart failure if not well controlled.

The concept of WHF is evolving, having been mentioned in recent updates to the HF guidelines of the European Society of Cardiology and the AHA/ACC/HFSA8,9 (Table 2). This phase of the disease marks its degenerative progression and indicates a considerably worse prognosis, whose risk profile is estimated by the progression of the disease and the worsening of the set of symptoms, signs, and/or functional capacity, classifying it as a possible trajectory within stage C.10

– Definition of advanced HF defined by SBC, AHA/ACC, ESC, and Heart Failure Society of America guidelines
Criterion SBC ACC/AHA ESC HFSA
Severe and persistent symptoms despite optimized therapy ✔ ✔ ✔ ✔
Important functional limitation (NYHA functional class III or IV) ✔ ✔ ✔ ✔
Persistent dyspnea with daily living activities   ✔    
Recurrent hospitalizations ✔ ✔ ✔ ✔
Frequent unplanned emergency room visits ✔   ✔ ✔
Intolerance to maximum therapeutic optimization ✔ ✔   ✔
Target organ dysfunction ✔ ✔   ✔
Persistent hyponatremia ✔ ✔   ✔
Pulmonary or systemic congestion refractory to diuretic therapy ✔ ✔   ✔
Frequent CDI shocks ✔ ✔   ✔
Cardiac cachexia ✔ ✔   ✔
Systolic blood pressure often ≤90 mmHg   ✔    
Persistently high BNP or NTproBNP values ✔   ✔  
Severe LV dysfunction, with echocardiographic pattern of pseudonormal or restrictive filling ✔   ✔  
High filling pressures (PCP >16 mmHg +/- PVC >12 mmHg)     ✔  
Low capacity in the 6MWT (<300 m) or VO2 peak (<12-14 ml/kg/min), estimated to be of cardiac origin ✔   ✔ ✔
Severe LV dysfunction with reduced ejection fraction ✔   ✔ ✔
Dependence on intravenous inotropes ✔     ✔
Progressive RV dysfunction and secondary PH ✔     ✔

ACC/AHA: American College of Cardiology/American Heart Association; ICD: implantable cardioverter defibrillator; HF: heart failure; BNP: B-type natriuretic peptide; ESC: European Society of Cardiology; HFSA: Heart Failure Society of America; PH: pulmonary hypertension; NYHA: New York Heart Association; NT-proBNP: N-terminal fraction of type B natriuretic peptide; PCP: pulmonary capillary pressure; CVP: central venous pressure; 6MWT: 6-minute walk test; RV: right ventricle; LV: left ventricle; VO2: oxygen consumption. Adapted from Marcondes-Braga FG, et al.73

Approach and treatment of patients with recurrent hospitalizations and WHF

Patients with recurrent hospitalizations and WHF must undergo a thorough evaluation to exclude reversible causes of HF decompensation and ensure optimized treatment based on specific guidelines.11 Despite the challenges in identifying factors and scenarios that may accelerate readmission, there is a solid underlying rationale for the use of evidence-based medical therapies with an impact on symptomatic relief and hospitalizations in patients with HF, especially those with reduced ejection fraction (HFrEF).12 In addition to the scheduling of decongestive therapy with diuretics and other emergency measures highlighted in Figure 2, the introduction (or reintroduction) of medications that constitute the pillars of HF treatment should be initiated in rapid sequence during the care transition phase.13-15 The additive benefit of these therapies became apparent within a few weeks of use, which is why target or maximum tolerated doses of all drug classes should be sought as quickly as possible. Several medications have been significantly associated with reductions in HFrEF admissions, including digoxin, a combination of hydralazine and nitrate, beta-blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, neprilysin and angiotensin receptor (ARNI) inhibitors, antagonists of the mineracolorticoid receptor (ARM), sodium-glucose cotransport-2 inhibitors (iSGLT2), and ivabradine.16-27 Clinical trials in patients with WHF demonstrated the safety and efficacy of drugs, such as vericiguat, omencativ mecarbil, INRA, and iSGLT2, specifically in this high-risk population.28-32 In patients with HF with a preserved ejection fraction (HFpEF) and HF with a mildly reduced ejection fraction (HFrEF), who present symptoms and high levels of type B natriuretic peptide (BNP or N-terminal pro- BNP [NT-proBNP]), the use of iSGLT2, and to a lesser extent ARM, has also proven to be effective in reducing hospitalizations due to HF.33-38

– Decongestive therapy for WHF. Intravenous loop diuretic and sodium-glucose cotransporter-2 (SGLT2) inhibitor are fundamental therapies for decongestion in patients with worsening heart failure (WHF). Other adjuvant therapies may be considered in selected patients. MRA: mineralocorticoid receptor antagonist; IV: intravenous. Adapted from Greene et al.<xref ref-type="bibr" rid="B72"><sup>72</sup></xref>

Intravenous iron replacement, especially with carboxymaltose or ferric derisomaltose, is also recommended for patients with WHF and an iron deficiency in order to improve the functional status and quality of life, as well as to reduce readmissions.39-44 Furthermore, for practicality’s sake, patients hospitalized due to HF or those receiving outpatient intravenous diuretics already have intravenous access, which can further facilitate the administration of intravenous iron in clinical practice.

Ischemia testing in selected patients, the surgical or percutaneous treatment of heart valve diseases, the management of atrial and ventricular arrhythmias (including a high burden of premature ventricular contractions), resynchronization therapy, and the assessment of situations that may aggravate HF symptoms, such as the use of non-steroidal anti-inflammatory drugs, may also lead to a decrease in readmissions.45-47 Finally, the consideration of candidates for advanced HF therapies, including heart transplantation and ventricular assist devices, is appropriate for those with symptoms that are refractory to pharmacological therapeutic optimization, be it electrical and/or mechanical.48,49 Complementary tests, such as the cardiopulmonary exercise test or the 6-minute walk test, in addition to pulmonary artery catheterization, can be useful tools in the evaluation of these patients.

The potential of new technologies to monitor congestion and prevent readmissions is a developing field.50 To date, the remote monitoring method in patients with HF with the most convincing evidence is CardioMEMS, a device implanted percutaneously in the pulmonary artery, which transmits core blood pressure values to a safe server.51 CardioMEMS has been shown to be effective and safe in “real-life,” cost-effectiveness, and post-marketing studies, and it appears to be a promising strategy with the potential to be added to clinical practices.52-54 Clinical trials of non-invasive telemonitoring in HF often have conflicting results, due to differences in the populations studied, the health policies of each country, and the monitoring tools adopted.55-59 The use of natriuretic peptides (BNP or NT-proBNP) as markers of congestion is also part of the assessment and diagnosis of HF, and may be a useful complementary tool for predicting long-term prognosis and readmission.15,60-62

 Public health strategies to reduce heart failure readmissions

Identifying public health strategies that can reduce preventable readmissions would be valuable for patients, medical providers, and healthcare managers. Numerous specific interventions have been investigated to try to reduce readmission for HF, including patient education, discharge planning, medication reconciliation, the scheduling of return visits before discharge, early return after discharge, and telemonitoring/follow-up phone calls. However, these studies are typically narrow in scope, focusing on an isolated aspect of patient care and providing a one-size-fits-all approach, with conflicting results in the literature.59,63-66

In the United States, the Patient Protection and Affordable Care Act (ACA) was enacted in 2010, seeking to expand opportunities for access to health care and supporting innovative care delivery methods aimed at reducing healthcare costs in general. Among the remuneration models proposed by the ACA is the review of hospital payment methods through the incorporation of care performance indicators, such as hospital readmission. The Hospital Readmissions Reduction Program (HRRP), was created to try to reduce 30-day readmissions by reducing payments to providers with the worst performance, using a methodology adjusted to the profile of the participating institution.67 The HRRP changed the landscape of hospital readmissions and reimbursement in the United States by imposing substantial Medicare payment penalties on hospitals with higher-than-expected readmission rates.65 However, although it reduced the readmission rate from 18% to 16% between 2008 and 2016, the HRRP generated controversy for not considering medical complexity and socioeconomic differences between hospitals.68

Finally, it is important to mention that a large proportion of patients with HF are admitted for non-cardiovascular conditions, as HF is one of the many comorbidities that can increase the risk of future hospitalizations.5,69 A proposal for a domain-directed intervention model can be considered during each hospitalization for HF, with guidance for interventions that can reduce risks and challenges in the care of patients with HF and recurrent hospitalizations70 (Figure 3).

– Proposed targeted intervention model. Patient-centered strategy to reduce readmissions organized into six categories that connect the patient and their disease: therapeutic optimization, early reassessment, interpretability, neuropsychological status, financial resources and functional capacity. By evaluating deficiencies in each of these categories, hospital systems can selectively target interventions more efficiently to reduce readmissions. HF: heart failure; PCDT: Clinical Protocols and Therapeutic Guidelines. Adapted from Sperry et al.<xref ref-type="bibr" rid="B70"><sup>70</sup></xref>

Conclusion and future perspectives

HF continues to be an epidemiological, clinical, and financial challenge for patients, medical service providers, and healthcare managers. Advances in HF therapies have prolonged patient survival, but at the cost of greater clinical complexity and cost of care. Even when clinical treatment is effective in reducing readmissions due to HF, it is not clearly documented whether there is also an improvement in patient survival outcomes.71

Although temporary mechanical support has revolutionized the management of cardiogenic shock, the unavailability of prospective data based on robust randomized clinical trials limits our understanding of the risks and benefits of this technology for the patient with recurrent hospitalizations. As experience with long-term support increases, criteria and guidelines for patient selection must be standardized in order to contain the costs of care and improve post-implant outcomes, keeping patients out of the hospital environment and with a quality of life. In transplantation, work to expand the donor pool must continue, while investments in basic and translational research can help improve graft longevity. Research focused on myocardial recovery is urgently needed, as biochemical pathways capable of reversing, if not preventing, HF would radically change our approach to care. Lastly, we must continue to integrate patient-centered and symptom-based palliative care into our advanced HF management paradigm in an attempt to help patients not only live longer, but also live better.

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Study association

This study is not associated with any thesis or dissertation work.

Ethics approval and consent to participate

This article does not contain any studies with human participants or animals performed by any of the authors.

Sources of funding : There were no external funding sources for this study.

 Artigo de Revisão Como Mudar a História do Paciente com Insuficiência Cardíaca e Internações de Repetição? 0000-0002-2612-8040 Andrade Fernanda Almeida Concepção e desenho da pesquisa Obtenção de dados Redação do manuscrito e Revisão crítica do manuscrito quanto ao conteúdo 1 0009-0002-5042-2968 Monferdini Luana Concepção e desenho da pesquisa Obtenção de dados Redação do manuscrito e Revisão crítica do manuscrito quanto ao conteúdo 2 3 0000-0001-5982-8847 Vieira Jefferson Luís Concepção e desenho da pesquisa Obtenção de dados Redação do manuscrito e Revisão crítica do manuscrito quanto ao conteúdo 4 5 Brasil Universidade Federal de São Paulo/UNIFESP, São Paulo, SP – Brasil Brasil Hospital e Maternidade Celso Pierro – PUC Campinas, Campinas, SP – Brasil Brasil Hospital das Clínicas Botucatu – Unesp, Botucatu, SP – Brasil Brasil Hospital de Messejana Dr. Carlos Alberto Studart, Fortaleza, CE – Brasil Brasil Universidade Federal do Ceará, Fortaleza, CE – Brasil Correspondência: Jefferson Luís Vieira • Hospital de Messejana - Unidade de Transplante e Insuficiência Cardíaca - Av. Frei Cirilo, 3480. CEP 60864-190, Fortaleza, CE - Brasil E-mail: jefvieira@yahoo.com.br, jefvieira31@gmail.com

Potencial conflito de interesse

Dr. Jefferson Vieira declara remuneração para adjudicação de eventos clínicos pela ARO do Hospital Israelita Albert Einstein e remuneração para conferências pela AstraZeneca, Boehringer-Ingelheim & Eli Lilly, Novartis, Bayer, Pfizer, Merck e Viatris.

 Resumo

A insuficiência cardíaca (IC) é uma condição progressiva, caracterizada por períodos variáveis de estabilidade sintomática frequentemente interrompidos por episódios de agravamento. Esses momentos de deterioração clínica têm sido reconhecidos como uma fase distinta na trajetória da IC e indicam um prognóstico consideravelmente pior. A prevenção de readmissões de pacientes com IC é uma prioridade crescente para prestadores de serviços médicos, investigadores e gestores de saúde. Embora as terapias baseadas em evidências para o tratamento de pacientes com IC tenham aumentado, a implementação consistente dessas terapias e o desenvolvimento de novas estratégias para prevenir readmissões continuam a ser áreas para melhoria contínua. Nesta revisão, discutiremos algumas propostas e desafios associados à redução das readmissões por IC.

 Insuficiência Cardíaca Diuréticos Hospitalização Mortalidade Introdução

A insuficiência cardíaca (IC) é uma condição complexa e progressiva, caracterizada por períodos variáveis de estabilidade sintomática usualmente interrompidos por episódios de descompensações, após as quais o paciente não retorna à sua qualidade de vida inicial. (Figura 1) Mesmo durante a fase de aparente estabilidade clínica, ainda persiste um risco residual significativo de deterioração clínica associado a readmissões recorrentes e novos eventos cardiovasculares que contribuem para a piora da doença.1,2 Essa jornada continua em uma trajetória descendente até a falência final da bomba e morte, ou, em uma minoria dos casos, o transplante de coração.

– Jornada e perfis de risco do paciente com insuficiência cardíaca. O diagnóstico de IC acarreta um risco clínico intrínseco significativo (risco basal), que pode ser reduzido através do emprego da terapia médica baseada nas diretrizes. Mesmo durante a fase de aparente estabilidade clínica, ainda persiste um risco residual de deterioração clínica que pode estar associado a readmissões recorrentes e novos eventos cardiovasculares (Worsening Heart Failure). As setas representam a direcionalidade entre os perfis de risco – pacientes na fase de agravamento podem responder à terapia otimizada e retornar a um estado de risco residual ou podem progredir para o estágio de risco avançado. CDI: cardiodesfibrilador implantável; IC: insuficiência cardíaca; TRC: terapia de ressincronização cardíaca. Adaptado de Greene et al.<xref ref-type="bibr" rid="B1"><sup>1</sup></xref>

De acordo com o maior banco de dados de fontes pagadoras para internação hospitalar dos Estados Unidos, o Nationwide Inpatient Sample (NIS), as hospitalizações por IC no país aumentaram de 1.060.540 em 2008 para 1.270.360 em 2018.3 Entretanto, tem sido cada vez mais evidente que nem todos os pacientes com IC descompensada são hospitalizados, pois muitos desses pacientes são manejados em regime ambulatorial.4,5 De fato, parte significativa dos doentes hospitalizados por IC agudamente descompensada apresentam repetidas visitas não planejadas ao consultório médico ou ao departamento de emergência antes da admissão. No ano de 2019 foram registradas somente nos Estados Unidos mais de 1.500.000 consultas de emergência com o diagnóstico de IC descompensada.3 Esses momentos de deterioração clínica têm sido caracterizados como uma fase distinta na trajetória do paciente com IC, chamada de Agravamento da insuficiência cardíaca (Worsening Heart Failure, ou WHF) (Figura 1).1,6 A WHF é definida pela progressão dos sinais e sintomas de IC em pacientes com disfunção ventricular crônica apesar de terapia médica otimizada, e envolve a necessidade de hospitalização ou do escalonamento terapêutico em regime ambulatorial, em geral com aumento da diureticoterapia. Isso porque o principal mecanismo patofisiológico de descompensação aguda da IC é a congestão, e não o baixo débito. De acordo com dados do registro Brasileiro de internações por IC, BREATHE extension, o perfil clínico-hemodinâmico predominante nas admissões por IC no país entre 2011 e 2018 foi quente-úmido (71,7%) enquanto uma minoria dos pacientes (12,9%) não apresentava sinais de congestão nem de má perfusão;7 entre mais de 3.000 indivíduos avaliados, a principal causa de descompensação foi a baixa adesão à terapia medicamentosa, em 28% dos pacientes, seguida por infecções (21%) e arritmia (14%). A diversidade dos gatilhos de readmissão destaca a importância do cuidado integral para prevenir complicações de condições secundárias e fatores de risco específicos do paciente (Tabela 1).

– Causas para o agravamento da insuficiência cardíaca
Baixa adesão à terapia medicamentosa O não cumprimento das prescrições de medicamentos conforme orientação de um profissional de saúde pode levar ao agravamento dos sintomas e ao declínio da função cardíaca.
Aumento da ingestão de sal e água Consumir muito sal (sódio) pode causar retenção de líquidos, o que pode piorar os sintomas de insuficiência cardíaca. Não monitorar a ingestão de líquidos e exceder os limites recomendados também pode ser problemático.
Eventos cardíacos Infarto do miocárdio ou outros eventos cardíacos podem enfraquecer ainda mais o músculo cardíaco, levando ao agravamento da insuficiência cardíaca.
Infecções As infecções, principalmente as respiratórias, podem sobrecarregar o coração e piorar os sintomas.
Arritmias Ritmos cardíacos irregulares podem reduzir a eficiência de bombeamento do coração e contribuir para o agravamento da insuficiência cardíaca.
Estilo de vida Tabagismo, consumo excessivo de álcool e falta de atividade física podem agravar a insuficiência cardíaca.
Outras condições médicas Condições como hipertensão, diabetes e doenças renais podem piorar a insuficiência cardíaca se não forem bem controladas.

O conceito de WHF está evoluindo, tendo sido mencionado em recentes atualizações das diretrizes de IC da Sociedade Europeia de Cardiologia e da AHA/ACC/HFSA.8,9 (Tabela 2) Essa fase da doença assinala sua progressão degenerativa e indica um prognóstico consideravelmente pior, cujo perfil de risco é estimado pela progressão da doença e pelo agravamento do conjunto de sintomas, sinais e/ou capacidade funcional, classificando-o como uma possível trajetória dentro do estágio C.10

– Definição de IC avançada pelas diretrizes SBC, AHA/ACC, ESC e Heart Failure Society of America
Critério SBC ACC/AHA ESC HFSA
Sintomas graves e persistentes apesar de terapia otimizada ✔ ✔ ✔ ✔
Limitação funcional importante (classe funcional NYHA III ou IV) ✔ ✔ ✔ ✔
Dispneia persistente com atividades da vida diária   ✔    
Hospitalizações recorrentes ✔ ✔ ✔ ✔
Visitas frequentes não planejadas à emergência ✔   ✔ ✔
Intolerância a otimização terapêutica máxima ✔ ✔   ✔
Disfunção de órgão-alvo ✔ ✔   ✔
Hiponatremia persistente ✔ ✔   ✔
Congestão pulmonar ou sistêmica refratária a diureticoterapia ✔ ✔   ✔
Choques de CDI frequentes ✔ ✔   ✔
Caquexia cardíaca ✔ ✔   ✔
Pressão arterial sistólica frequentemente ≤90 mmHg   ✔    
Valores de BNP ou NTproBNP persistentemente elevados ✔   ✔  
Disfunção grave de VE, com padrão ecocardiográfico de enchimento pseudonormal ou restritivo ✔   ✔  
Pressões de enchimento elevadas (PCP >16 mmHg +/- PVC >12 mmHg)     ✔  
Baixa capacidade no TC6m (<300 m) ou VO2 pico (<12-14 ml/kg/min), estimado de origem cardíaca ✔   ✔ ✔
Disfunção grave de VE com fração de ejeção reduzida ✔   ✔ ✔
Dependência de inotrópicos intravenosos ✔     ✔
Disfunção progressiva de VD e HP secundária ✔     ✔

ACC/AHA: American College of Cardiology/American Heart Association; CDI: cardiodesfibrilador implantável; IC: insuficiência cardíaca; BNP: peptídeo natriurético do tipo B; ESC: European Society of Cardiology; HFSA: Heart Failure Society of America; HP: hipertensão pulmonar; NYHA: New York Heart Association; NT-proBNP: fração N-terminal do peptídeo natriurético do tipo B; PCP: pressão capilar pulmonar; PVC: pressão venosa central; TC6m: teste de caminhada de 6 minutos; VD: ventrículo direito; VE: ventrículo esquerdo; VO2: consumo de oxigênio. Adaptado de Marcondes-Braga et al.73

Abordagem e tratamento do paciente com internações de repetição e WHF

Pacientes com internações de repetição e WHF devem passar por uma avaliação minuciosa para excluir causas reversíveis de descompensação da IC e garantir o tratamento otimizado com base nas diretrizes.11 Apesar dos desafios na identificação de fatores e situações que possam antecipar a readmissão, existe um fundamento sólido para a utilização de terapias médicas baseadas em evidência com impacto sobre alívio sintomático e hospitalizações em pacientes com IC, especialmente naqueles com fração de ejeção reduzida (ICFEr).12 Além do escalonamento da terapia descongestiva com diuréticos e outras medidas de resgate destacadas na Figura 2, a introdução (ou reintrodução) de medicações que constituem os pilares do tratamento da IC deve ser iniciada em sequência rápida ainda na fase de transição de cuidados.13-15 O benefício aditivo dessas terapias tornou-se aparente em algumas semanas de uso, razão pela qual as doses alvo ou máximas toleradas de todas as classes de medicamentos devem ser buscadas o mais rapidamente possível. Diversos medicamentos foram significativamente associados a reduções nas admissões por ICFEr, incluindo digoxina, combinação de hidralazina e nitrato, betabloqueadores, inibidores da enzima de conversão da angiotensina, bloqueadores do receptor da angiotensina, inibidores da neprilisina e do receptor de angiotensina (INRA), antagonistas do receptor mineracolorticoide (ARM), inibidores do cotransporte de sódio-glicose-2 (iSGLT2) e ivabradina.16-27 Ensaios clínicos em pacientes com WHF demonstraram a segurança e eficácia de fármacos como vericiguate, omencativ mecarbil, INRA e iSGLT2 especificamente nessa população de alto risco.28-32Já em portadores de IC com fração de ejeção preservada (ICFEp) e IC com fração de ejeção levemente reduzida (ICFElr), que apresentam sintomas e níveis elevados de peptídeo natriurético tipo B (BNP ou N-terminal pro-BNP [NT-proBNP]), o uso de iSGLT2, e em menor grau de ARM, também se mostrou eficaz na redução da hospitalizações por IC.33-38

– Terapia descongestiva para WHF. Diurético de alça intravenoso e o inibidor do cotransportador de sódio-glicose-2 (SGLT2) são terapias fundamentais para descongestão nos pacientes com agravamento da insuficiência cardíaca (WHF). Outras terapias adjuvantes podem ser consideradas em pacientes selecionados. ARM: antagonista do receptor mineralocorticoide; EV: endovenoso. Adaptado de Greene et al.<xref ref-type="bibr" rid="B72"><sup>72</sup></xref>

A reposição intravenosa de ferro, em particular com carboximaltose ou derisomaltose férrica, também é recomendada para pacientes com WHF e deficiência de ferro para melhorar o estado funcional e a qualidade de vida, e reduzir readmissões.39-44 Além disso, por uma questão de praticidade, pacientes hospitalizados por IC ou que recebem diuréticos intravenosos ambulatoriais já possuem acesso intravenoso, o que pode facilitar ainda mais a administração de reposição de ferro conforme diretrizes na prática clínica.

Testes de isquemia em pacientes selecionados, tratamento cirúrgico ou percutâneo de doenças valvares, manejo de arritmias atriais e ventriculares (incluindo alta carga de contrações ventriculares prematuras), terapia de ressincronização e avaliação de situações que possam agravar os sintomas de IC, tais como o uso de anti-inflamatórios não esteroidais, também podem influenciar na redução das readmissões.45-47 Finalmente, a consideração de candidatos a terapias avançadas da IC, incluindo transplante de coração e dispositivos de assistência ventricular, é apropriada para aqueles com sintomas refratários à otimização terapêutica farmacológica, elétrica e/ou mecânica.48,49 Exames complementares, como o teste de esforço cardiopulmonar ou o teste de caminhada de 6 minutos, além do cateterismo de artéria pulmonar, podem ser ferramentas úteis na avaliação desses pacientes.

O potencial das novas tecnologias para monitorar congestão e prevenir readmissões é um campo em desenvolvimento.50 Até o momento, o método de monitoramento remoto em doentes com IC com evidências mais convincentes é o CardioMEMS, um dispositivo implantado via percutânea na artéria pulmonar que transmite os valores pressóricos centrais para um servidor seguro.51 O CardioMEMS mostrou-se eficaz e seguro em estudos de “vida real”, de custo-efetividade e de pós-comercialização e parece ser uma estratégia promissora com potencial de ser acrescentada à prática clínica.52-54 Ensaios clínicos de telemonitoramento não-invasivo em IC costumam ter resultados conflitantes, devido a diferenças nas populações estudadas, políticas de saúde de cada país e ferramentas de monitoração adotadas.55-59 O uso de peptídeos natriuréticos (BNP ou NT-proBNP) como marcadores de congestão também faz parte da avaliação e diagnóstico da IC, podendo ser uma ferramenta complementar útil para predição de prognóstico a longo prazo e de reinternação.15,60-62

 Estratégias de saúde pública para reduzir readmissões por insuficiência cardíaca

Identificar estratégias de saúde pública que possam reduzir readmissões preveníveis seria valioso para pacientes, prestadores de serviços médicos e gestores de saúde. Inúmeras intervenções específicas já foram investigadas para tentar diminuir a readmissão por IC, incluindo educação dos pacientes, planejamento de alta, conciliação de medicamentos, agendamento do retorno antes da alta, retorno precoce após a alta e telemonitoramento/ligações telefônicas de acompanhamento. No entanto, esses estudos são normalmente de âmbito restrito, centrando-se num aspecto isolado do cuidado do paciente e proporcionando uma abordagem única para todos os casos, com resultados conflitantes na literatura.59,63-66

Nos Estados Unidos, foi promulgado em 2010 o Patient Protection and Affordable Care Act (ACA), voltado para ampliar oportunidades de acesso à saúde e apoiar métodos inovadores de prestação de cuidados destinados a reduzir os custos de saúde em geral. Entre os modelos de remuneração propostos pelo ACA, está a revisão da forma de pagamento hospitalar por meio da incorporação de indicadores de desempenho assistencial, como a readmissão hospitalar. O Programa de Redução das Readmissões Hospitalares (Hospital Readmissions Reduction Program, ou HRRP) foi criado para tentar diminuir as readmissões de 30 dias, reduzindo o pagamento aos prestadores com pior performance, utilizando uma metodologia ajustada para o perfil da instituição participante.67 O HRRP mudou o panorama das readmissões hospitalares e de reembolso nos Estados Unidos, impondo penalidades substanciais no pagamento do Medicare a hospitais com taxas de readmissão superiores às esperadas.65 No entanto, embora tenha reduzido o índice de readmissões de 18% para 16% entre 2008 e 2016, o HRRP gerou controvérsias por não considerar a complexidade médica e as diferenças socioeconômicas entre os hospitais.68

Por fim, vale mencionar que grande parte dos pacientes com IC é admitida por condições não cardiovasculares, pois a IC é uma das muitas comorbidades que podem aumentar o risco de futuras hospitalizações.5,69 Uma proposta de modelo de intervenção direcionado por domínios pode ser considerada durante cada hospitalização por IC, com orientação para intervenções que possam diminuir riscos e desafios no cuidado de pacientes com IC e internações de repetição70 (Figura 3).

– Proposta de modelo de intervenção direcionada. Estratégia centrada no paciente para reduzir readmissões organizada em seis categorias que interligam o paciente e sua doença: otimização terapêutica, reavaliação precoce, capacidade de interpretação, estado neuropsicológico, recursos financeiros e capacidade funcional. Ao avaliar as deficiências em cada uma destas categorias, os sistemas hospitalares poderão direcionar seletivamente intervenções de forma mais eficiente para reduzir readmissões. IC: insuficiência cardíaca; PCDT: Protocolos Clínicos e Diretrizes Terapêuticas. Adaptado de Sperry et al.<xref ref-type="bibr" rid="B70"><sup>70</sup></xref>

Conclusão e perspectivas futuras

A IC continua sendo um desafio epidemiológico, clínico e financeiro para pacientes, prestadores de serviços médicos e gestores de saúde. O avanço nas terapias de IC tem prolongado a sobrevida dos pacientes, mas à custa de maior complexidade clínica e custo de cuidados. Mesmo quando o tratamento clínico é eficaz em reduzir readmissões por IC, não está claramente documentado se também há melhora nos resultados de sobrevida dos pacientes.71

Embora o suporte mecânico temporário tenha revolucionado o manejo do choque cardiogênico, a indisponibilidade de dados prospectivos baseados em ensaios clínicos randomizados robustos limita nossa compreensão sobre os riscos e benefícios dessa tecnologia para o paciente com internações de repetição. À medida que a experiência com o suporte de longa permanência aumenta, critérios e diretrizes para seleção de pacientes devem ser padronizados de modo a conter os custos do cuidado e melhorar os resultados pós-implante, mantendo os pacientes fora do ambiente hospitalar e com qualidade de vida. No transplante, o trabalho para expandir o pool de doadores deve continuar, ao mesmo tempo em que investimentos em pesquisa básica e translacional podem ajudar a melhorar a longevidade do enxerto. Pesquisas focadas na recuperação miocárdica são urgentemente necessárias, pois vias bioquímicas capazes de reverter, se não prevenir, a IC, mudariam radicalmente nossa abordagem ao cuidado. Por último, devemos continuar a integrar o cuidado paliativo centrado no paciente e baseado em sintomas em nosso paradigma de manejo da IC avançada, na tentativa de ajudar pacientes não apenas a viver mais tempo, mas a viver melhor.

Fontes de financiamento: O presente estudo não teve fontes de financiamento externas.