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

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. β-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, β-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.