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Cândida Fonseca

Publications and source records attributed to Cândida Fonseca.

14 recordsLinked to original sources
PubMed2006

Diagnosis of heart failure in primary care.

Heart failure is becoming an increasing concern to healthcare worldwide. It is the only cardiovascular disorder that continues to increase in both prevalence and incidence, and as the population continues to age, it is expected that the prevalence of this disease will continue to rise. Guidelines on diagnosis and treatment of heart failure are to be met. Most patients with heart failure will present themselves in general practice. Therefore, the community management of heart failure has become increasingly important and the role of General Practitioners even more crucial. Improving the reliability of diagnosis in primary care is essential since determining the aetiology and stage of heart failure leads to different management choices to improve symptoms, quality of life and disease prognosis. Furthermore, early diagnosis is needed, when there may be no symptoms, since treatment can delay or reverse disease progression. Diagnostic methods may therefore need to encompass screening strategies, as well as symptomatic case identification, in the future. General Practitioners must make correct decisions regarding appropriate further investigation, treatment and referral. A correct diagnosis is the cornerstone leading to effective management. The aim of this paper is to review the role of symptoms and signs and diagnostic tests, such as, chest X-ray, ECG, natriuretic peptides and echocardiography, for diagnosing heart failure in the primary care setting. Improving diagnostic skills remains a continuous challenge for clinicians. Simple and reliable diagnostic procedures are crucial to comply with Guidelines and reduce healthcare utilisation and costs.

Cardiac Output, Low↗
PubMed2006

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.

Acute Disease↗
PubMed2006

Recurrent syncope--a diagnostic challenge.

Several disorders resemble syncope. According to the European Society of Cardiology guidelines, certain key questions should be addressed during the initial evaluation of a patient presenting syncope. The physician should be alert to important clinical features that suggest the diagnosis and the evaluation strategy. However, syncope remains a diagnostic challenge. The authors report a case of a 60-year-old man admitted to the Emergency Department (ED) complaining of recurrent syncopal attacks that had begun one month before. He had daily transient, self-limited loss of consciousness lasting for seconds or even a few minutes, followed by prompt recovery. The attacks occurred mainly after exercise or urination. Prodromal symptoms were sweating and a sensation of imminent death. He learned to recognize these symptoms, reporting that he could control the duration of the attack by sitting down and voluntarily hyperventilating. He reported no prior pain, palpitations, tongue-biting or urinary incontinence. The episodes were witnessed and no abnormal movements were reported. The patient had been healthy until two months before, when he was diagnosed with diabetes mellitus by his general practitioner after routine analyses. Glycemia was controlled with diet and subcutaneous Actrapid insulin. No history of cardiac, cardiopulmonary, neurological or psychiatric disease was found and he was taking no other medication. On admission to the Emergency Department he was asymptomatic. Clinical examination was normal. The ECG showed sinus rhythm, heart rate of 70 bpm, and left bundle branch block; (LBBB). The chest X-ray was normal. As some medical features suggested a cardiac etiology (post-exercise, LBBB) and others indicated a neurally-mediated reflex syndrome or even situational syncope (after urination), a diagnostic strategy to exclude cardiac cause was adopted, including echocardiogram, and 24-hour ECG monitoring and stress test. The echocardiogram was normal. During Holter monitoring, he reported a syncopal event, in supine position, immediately after urination, and a 50-second period of cardiac arrest with persistent P waves--P-wave asystole--was recorded. Cardiac bradyarrhythmia was thus established as the cause of the syncope and a permanent pacemaker was implanted, with no recurrence of symptoms. This example of an unusually long-lasting cardiac arrest with spontaneous recovery illustrates the non-specific nature of clinical features and how difficult it is to diagnose syncope in an Emergency Department setting. The authors briefly review the topic according to recent guidelines.

Algorithms↗
PubMed2005

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.

Adult↗
PubMed2004

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.

Adult↗
PubMed2004

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.

Adult↗
PubMed2004

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.

Aged↗
PubMed2004

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.

Adult↗
PubMed2004

[Epidemiology of heart failure in mainland Portugal: new data from the EPICA study].

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.

Heart Failure↗
PubMed2004

Levosimendan in daily intensive care practice--the experience of 15 centers. Background, methods and organization of the PORTLAND study.

INTRODUCTION: The LIDO and RUSSLAN trials showed that levosimendan was well tolerated and had a stronger hemodynamic effect than dobutamine and a positive impact on prognosis. There are, however, few data regarding its effectiveness and safety when used in an everyday clinical setting. OBJECTIVE: To test the hypothesis that in day-to-day practice conditions levosimendan is both effective and safe for the treatment of decompensated heart failure (HF). This primary combined endpoint of effectiveness and safety was evaluated at 24 hours and 5 days after the beginning of the treatment. DESIGN: Prospective, multicenter, nonrandomized clinical trial with evaluations at baseline, 24 hours, 5 days, and 3 and 6 months. Follow-up for 6 months. SETTING: The intensive care units of 15 cardiology or internal medicine departments. PATIENTS: 129 consecutive patients requiring inotropes due to decompensated systolic HF despite maximally tolerated oral therapy. INTERVENTION: 24-hour infusion of levosimendan via a central or peripheral vein. MEASUREMENTS AND EVALUATION OF RESULTS: 1. Monitoring: Continuous ECG monitoring, non-invasive blood pressure, urinary output, oximetry. Invasive monitoring was not required. 2. Follow-up. Baseline evaluation: history, physical examination, ECG, 2D echocardiogram, hemogram, ionogram, liver and kidney function. 24-hour and 5-day evaluations: symptoms, physical examination, recording of medical therapy and previous 24-hour urinary output, ECG, hemogram, ionogram, liver and kidney function, and evaluation of arrhythmic episodes and heart rate and blood pressure trends in previous 24 hours. 3- and 6-month evaluations: number of hospital admissions and length of hospital stay due to HF, and mortality. 3. Evaluation of primary endpoint. EFFECTIVENESS: assessed by a clinical score including 2 subjective parameters (1. NYHA functional class, 2. patient self-evaluation symptom class) and 6 objective parameters (3. body weight, 4. pulmonary congestion, 5. previous 24-hour diuresis, 6. serum creatinine, 7. oral HF medication, 8. intravenous HF medication). Definition of clinical effectiveness: improvement in > or = 1 subjective parameters plus improvement in > or = 1 objective parameters, with all other parameters unchanged. SAFETY: The therapy was judged safe in the absence of any serious adverse event with a probable or undetermined causal relationship with levosimendan. Primary endpoint evaluation: Patients reached the primary endpoint when levosimendan was both effective and safe according to the above definitions.

Critical Care↗
PubMed2002

How patients with heart failure are managed in Portugal.

The prevalence of heart failure is increasing all over the world. It is a common and growing public health problem in Portugal as in many other European countries. This article provides a review of health service organization and current heart failure management in Portugal, discusses primary care and ward practices in different hospitals and reports on the use of proven standard therapies for the treatment of heart failure in the community. Despite major advances in diagnosis and treatment, heart failure is only satisfactorily managed. Furthermore efforts are necessary before the beneficial effects observed in trials have a real impact in clinical practice. A broader view and priority for the management of this syndrome on a national level are needed to improve the quality of heart failure care in Portugal.

Cardiotonic Agents↗
PubMed2002

Prevalence of chronic heart failure in Southwestern Europe: the EPICA study.

AIM: To estimate the prevalence of chronic heart failure (CHF) in mainland Portugal in 1998. METHODS AND POPULATION: A community-based epidemiological survey involving subjects attending primary care centres selected by a combined two-stage sampling and stratified procedure. General practitioners (GPs) randomly selected in proportion to the population of the District, evaluated subjects attending primary care centres aged over 25 years, recruited consecutively and stratified by age. CHF cases were identified according to the Guidelines of the European Society of Cardiology for CHF diagnosis. RESULTS: 5434 eligible subjects were evaluated by 365 GPs; 551 patients with CHF were identified. The overall prevalence and 95% CI of CHF in mainland Portugal is 4.36% (3.69-5.02%), 4.33% in males (3.19-5.46%), and 4.38% in females (3.64-5.13%). Age-specific CHF prevalence was as follows: 1.36% in the 25-49 years-old group (0.39-2.33%), 2.93% in the 50-59 years-old group (5.58-9.37%), 7.63% in the 60-69 years-old group (5.58-9.37%), 12.67% in the 70-79 years-old group (10.73-14.6%), and 16.14% in group over 80 years old (13.81-18.47%). The prevalence of CHF due to systolic dysfunction was 1.3% and the prevalence of CHF with normal systolic function was 1.7%. CONCLUSIONS: The overall prevalence of CHF in Portugal was slightly higher than that of other European studies and increases sharply with age. The prevalence of CHF due to systolic dysfunction is very similar to that reported by other recent European studies. The differences found may correspond to differences in methodology rather than actual differences in the population.

Adult↗
PubMed2002

Heart transplantation in Portugal: current status and future perspectives.

No other form of therapy, whether medical or surgical, has an impact comparable to heart transplantation on the quality of life and survival of selected patients with severe heart failure. In the EU and in the USA about 10 patients per million of population are transplanted each year. In Portugal, a country with a population of 10 million, 100 patients should be transplanted each year, but only 12 patients were in fact transplanted in 1999. We rank 17th, in terms of the rate of heart transplantation per million of population, among the 23 European countries with registries of this activity. This is due to structural and organizational deficiencies of three main types: the lack of professional teams dedicated to severe heart failure treatment and heart transplantation; the lack of infrastructure, particularly heart failure wards and heart failure outpatient clinics; and the inappropriate distribution of the tasks associated with heart transplantation and patient follow-up. We present an estimate of the number of potential heart transplant candidates in Portugal, based on the EPICA study and a prediction of the resources needed for a successful heart transplantation program serving a population of 2 million. This was based on what is known of the natural history, morbidity and mortality of severe heart failure, on our own experience in this field, and finally on the experience of a large international heart transplantation center. The recommendations of the British Transplantation Society and those of the Department of Cardiothoracic Surgery of Stanford University were also taken into account.

Forecasting↗