The heart failure in Internal Medicine in Tuscany: the SMIT Study

Abstract

The incidence and prevalence associated with the growing age of population have made heart failure (HF) a new epidemic. In Italy most of HF patients are admitted to Internal Medicine Departments (IMD). We conducted a 30-day cross-sectional study involving patients with HF admitted to IMD of Tuscany. The aim of the study was to provide an updated snapshot of in-hospital management of HF in Tuscany and to analyze the differences in relation to the most recent guidelines. We have recruited 770 patients (M=45.4%) with a mean age of 82.5±8.9 years. Only 16.1% had a de novo HF. Most of them were re-admitted for decompensated HF. Hypertension and ischemic disease are the prevailing etiologies. HF alone was in less than 2%. 71.5% of patients had more than two comorbidities and 40.6% more than three concomitant diseases. The mean hospital stay (overall 8.6±5.5 days) correlated with the number of comorbidity. About 25% of patients had a creatinine clearance <30 mL/min. Nearly 50% of patients had atrial fibrillation but only the half was anti-coagulated. b-blockers, angiotensin converting enzyme-inhibitors (ACE-I) or angiotensin receptor blockers (ARB) were prescribed in about two-thirds of the subjects. Echocardiography was performed in 64.1% of patients. BNP or NT-pro BNP was tested in 67% at the hospital admission and in 18.3% at the discharge. At the discharge 50.1% of patients had loss of autonomy, 57% a polypharmacy prescription (≥8 classes of medicines) and 21.2% needed domiciliary oxygen therapy, but despite these critical points only 8% of the patients were transferred to long-term/intermediate care settings. In conclusion, the main characteristics of patients with HF admitted to IMD in Tuscany are the advanced age (the patients are old and very old) and the presence of multiple comorbidities (HF alone is a rarity indeed). The use of echocardiography and the pharmacological therapy with ACE-I, ARB, b-blocker and anti-aldosterone agents is wider than previous surveys, but some diagnostic, therapeutic and prognostic aspects are not similar to that recommended by the most recent HF guidelines. This survey underscores again some differences between HF trials world and HF real world, where the management is probably also driven by a clinical holistic approach. Correspondence: Valerio Verdiani, via Faccioli 15, 50145 Firenze, Italy. Tel.: +39.366.6581380 -Fax: +39.0564.48533. E-mail: verdiani@fastwebnet This work is licensed under a Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0).

Results of prospective multicenter study on heart failure on Campania Internal Medicine wards: the FASHION study

“…These features are confirmed in another recent Italian study on 770 patients with HF observed in Internal Medicine wards, showing a mean age of 82.5 years. 23 Results of the present study agree with the above-mentioned data (mean age of 76.9 years, with 76% of patients older than 70 years). In a subgroup analysis in our whole series (Table 3), we observed several statistically significant age-differences as regards etiological factors, comorbidity and cardiac rhythm; all the same, some medications such as β-blockers, oral anticoagulant and double antiplatelet agents were significantly less frequent assumed in older patients.…”

“…25 Various comorbidities usually coexist in elderly patients and contribute to the development of HF, end stage heart disease and death ant this negative prognostic impact of concomitant diseases has been documented in several studies. [22][23][24]26 In the present survey we have observed that 64.9% patients had more than two chronic conditions, with a higher, but non-significant, prevalence in women. These results are quite similar to that of the above-mentioned Italian study.…”

“…These results are quite similar to that of the above-mentioned Italian study. 23 The most frequent comorbidities we registered were arterial hypertension (76.9%), COPD 49.4% and diabetes (42%). Previous epidemiological studies demonstrated similar high prevalence of diabetes in patients with HF, that is nearly four time greater than the prevalence of diabetes in the general population.…”

Sacubitril/valsartan: from the PARADIGM-HF trial results to heart failure patients in internal medicine. A narrative review

“…18 In the SMIT study (an observational study performed on 770 patients admitted for HF to 32 departments of internal medicine in Tuscany, a region of central Italy), there was a female prevalence (F 55%, M 45%) and an average age of 82.5 years; 71.5% had at least three comorbidities, and 40.2% at least four comorbidities, in particular arterial hypertension, renal impairment, atrial fibrillation, COPD, and diabetes mellitus. 19 Preserved left systolic ventricular function is more frequent in internal medicine wards than in cardiology wards. In the TEMISTOCLE study, 40.8% of patients admitted to internal medicine had ejection fraction (EF) >40%, vs 28.4% of those admitted to cardiology.…”

“…42 Cognitive defects were found in 30% of HF patients admitted to internal medicine wards. 19 Neprilysin is responsible for the breakdown of peptides, including amyloid-beta peptide. It has been hypothesized that inhibiting neprilysin may elevate levels of this peptide in the brain.…”