IJCS | Volume 32, Nº6, November / December 2019

602 Nicolao et al. Heart failure: morbidity and mortality Int J Cardiovasc Sci. 2019;32(6):596-604 Original Article and are more likely to have heart failure with preserved ejection fraction (HFpEF). 18 A previous study that assessed HF patients, according to age groups, showed an inversion in prevalence after the seventh decade of life, with a female prevalence. This fact can be explained due to women’s higher life expectancy compared to men. 10 The Ministry of Health attributed the higher rates of admissions among men to their greater vulnerability to diseases, especially to severe and chronic illnesses, and to the fact that they die earlier than women do. Regardless of the higher vulnerability and elevated mortality rates, men do not search for basic healthcare services, in the same proportion as momen. 21 In relation to the length of stay, this study showed an increase in the period of hospitalization of HF patients, and the most expressive increase occurred in Brazil, with a variation of 21%. A previous study that assessed the average length of stay of adult HF patients in the National Health Service (SUS) in Brazil reported an average length of stay of 5.8 days, in 2001, reaching 6.6 days, in 2012, which represents an increase of 12.12%. 9 However, a study carried out in Niterói (Rio de Janeiro), in 2001, reported an average length of stay of 12.6 days in public hospitals and 8 days in private hospitals. 13 Similar data were found in previous global studies, reporting an average length of stay of 5 to 6 days in North America, Asia and Argentina. 11,18,22 The present study found similar data, showing an increase in the length of stay in Brazil and RS. In Porto Alegre, we observed an increase in average length of stay throughout the period studied. This can be attributable to the higher number of hospitals and a greater offer in specialized centers and institutions linked to universities with a focus on teaching and research, providing qualified service in accordance with current guidelines, as well as a clear decrease in mortality rates, especially in Porto Alegre. Data equivalent to those from Porto Alegre are reported in previous studies, indicating 10 days of hospitalization in Western and Eastern Europe and low-income countries. 11,18 Even with technological advances in the treatment of HF and in spite of the reduction in hospitalization rates, the average length of stay and hospital costs have increased, probably as a result of patients’ clinical complexity. 10 A previous study that assessed the costs of heart failure-related hospitalizations in Brazil for 12 years showed a 132.8% increase in hospitalization costs in the period studied. The data obtained from this study also indicate an increase in the average cost per hospital admission. In Porto Alegre, the values are higher compared to the other regions studied, throughout the period considered, with a 135.2% increase in cost per hospitalization. These data should be correlated with the length of hospital stay, the percentage of admissions and mortality rates, which show an increase in length of stay and a decrease in admissions and mortality rates. Thus, we can conclude that the assistance provided to patients is related to better current practices, since in Porto Alegre patients had better clinical outcomes. In 2016, in Brazil, the costs of HF-related hospitalizations were R$ 334 million, accounting for 2% of total hospitalization costs. For this reason, there is an increasing search for the implementation of prophylactic and preventive measures. 14 In relation to mortality rates, a multicenter analysis performed in Brazil (BREATHE), showed that low treatment adherence accounts for a significant increase in morbidity, mortality and hospital costs. 8 However, the data obtained from this study show a decrease in in- hospital mortality rates throughout the 10 years studied. Porto Alegre showed a 61% decrease in mortality rates. Similarly, Brazil and Rio Grande do Sul had a decrease of 24.5% and 19%, respectively. A previous study that assessed HF-related mortality in Brazil showed a 41% increase in mortality in the period from 2001 to 2012. 10 This increased mortality rate was associated with patient severity and with the fact that many patients with heart failure are elderly. Nevertheless, the data obtained from this study show a decrease inmortality due toHF, which can be attributable to the advances in treatment over the last years. It is well known that the use of proper medication, in combination with non-pharmaceutical measures, such as multidisciplinary follow-up and monitoring, provide significant benefits to clinical prognosis and consequently decreased morbidity and mortality. Analysis of the results of the BREATHE study showed that 63% of the patients received guidelines on hospital discharge about the correct use of medications, whereas only 34.9%were advised about the diet to be followed at home and 16% were counseled about physical activity. 8 It is well known that lack of adherence to pharmacological and non-pharmacological treatment are among the reasons for decompensated HF and consequent hospitalization. 13,19,23 In this context, follow- up by a multi-professional team after hospital discharge