Cristina Gavina

Background/Objectives: Cardiovascular disease (CVD) remains the leading cause of morbidity and mortality worldwide, requiring coordinated long-term management of cardiovascular risk factors, complex pharmacotherapy, and continuity of care across healthcare settings. Community pharmacists are well-placed to support ambulatory cardiovascular care; however, their contribution often remains insufficiently integrated into cardiovascular care pathways, limiting continuity, information exchange, and coordinated medication management across community, primary, and specialist care. This study aimed to establish the scientific basis for the development of an Integrated Ambulatory Pharmaceutical Follow-Up Programme in Cardiology by synthesising the available evidence on pharmacist-led cardiovascular care. Methods: An evidence-informed narrative synthesis was conducted using targeted searches of PubMed/MEDLINE, Scopus, and Web of Science, complemented by manual screening of reference lists. Priority was given to systematic reviews, meta-analyses, randomised controlled trials, and high-quality observational studies addressing pharmacist-led interventions in cardiovascular risk management, heart failure, transitions of care, cardiac rehabilitation, and integrated pharmaceutical care. Evidence was mapped across clinical outcomes, care processes, professional roles, and implementation requirements and subsequently translated into the components of the proposed integrated ambulatory care framework. Results: The available evidence consistently indicates that pharmacist-led interventions improve cardiovascular risk factor control, medication adherence, pharmacotherapy optimisation, and patient-reported outcomes. Community pharmacies provide accessible and effective settings for cardiovascular risk screening, chronic disease monitoring, and structured follow-up. In heart failure, pharmacist involvement supports optimisation of guideline-directed medical therapy, while during care transitions it contributes to the identification and reduction in medication-related problems. In cardiac rehabilitation and secondary prevention, pharmacist-led care supports medication optimisation, adherence, and cardiovascular risk-factor management. Overall, the available evidence supports the integration of community pharmacists into multidisciplinary ambulatory cardiovascular care pathways and provides the evidence base for the proposed conceptual framework. Conclusions: The proposed Integrated Ambulatory Pharmaceutical Follow-Up Programme in Cardiology provides an evidence-informed conceptual framework to support the structured integration of community pharmacists into ambulatory cardiovascular care. Its implementation has the potential to strengthen continuity of care, optimise pharmacotherapy, and support improved cardiovascular outcomes when supported by collaborative practice models, interoperable health information systems, and appropriate organisational frameworks.

Diabetes and heart failure are strongly correlated, and people with diabetes are more likely to rapidly transition to overt heart failure and develop symptoms. Early identification and management of heart failure can improve outcomes. Elevated concentrations of the N-terminal pro-B-type natriuretic peptide (NT-proBNP) cardiac biomarker are associated with increased risk of cardiovascular events and mortality in people with diabetes, and measurement of this biomarker is now recommended for early detection of Stage B heart failure (asymptomatic cardiac dysfunction), according to American Diabetes Association (ADA) guidelines. While several countries have published local consensus statements on how to address heart failure risk in diabetes, this assessment has not yet been universally adopted in practice. A multidisciplinary group of experts from ten countries (Ireland, Italy, Lithuania, Portugal, Slovenia, Spain, Switzerland, Turkey, India, and the USA) convened to discuss their experience of implementing ADA guidelines in clinical practice. This review reports their experiences in context with existing literature on the subject, providing updated guidance on how local caregivers and multidisciplinary teams can effectively implement and manage NT-proBNP-based early detection of heart failure risk in people with diabetes at a national level. Country-specific implementation efforts must consider multiple parameters for any early detection program, including: 1) The patient pathway; 2) The availability of resources; 3) The educational needs of clinicians; and 4) Cost-effectiveness. A multipronged approach with a clear pathway for evaluation, diagnosis, and treatment is therefore required to facilitate the implementation of NT-proBNP programs for early heart failure detection on a global level. This review discusses the approaches proposed in different countries, fine-tuning the population in scope and the thresholds for biomarker interpretation and subsequent action, to achieve sustainable programs for early heart failure identification and management.

Respiratory syncytial virus (RSV) is an important cause of acute respiratory infection (ARI) in older adults,1,2 especially during winter.2,3 RSV-ARI is associated with substantial morbidity and mo...

Background: Obesity is linked to heart failure, particularly with preserved ejection fraction, but is associated with lower natriuretic peptide levels, potentially leading to underdiagnosis. Aims: To examine the association between adiposity measures—body mass index, waist circumference, and waist-to-height ratio—and N-terminal pro-B-type natriuretic peptide levels, and to determine if lower cut-offs should be used to rule out heart failure in individuals with obesity. Methods: PORTHOS is a 2023 population-based study in Portugal including adults aged 50 years or older. Participants underwent N-terminal pro-B-type natriuretic peptide screening, followed by clinical and echocardiographic assessment in those with levels >= 125 pg/mL, self-reported heart failure, or a 5% random sample with levels 70% using waist-to-height ratio ≥0.6. Body mass index showed a strong inverse association with N-terminal pro-B-type natriuretic peptide, with approximately 50 pg/mL lower levels per 5 kg/m² increase. Individuals with obesity and peptide levels < 125 pg/mL had higher odds of heart failure symptoms (odds ratio 1.97, 95% confidence interval 1.15–3.38) and echocardiographic abnormalities (odds ratio 3.63, 95% confidence interval 1.27–10.4) than lean participants with levels >= 125 pg/mL, despite being 9 years younger and having fourfold lower median peptide levels (59 vs 235 pg/mL). Conclusions: Obesity is associated with lower N-terminal pro-B-type natriuretic peptide levels despite a higher burden of symptoms and structural abnormalities. Fixed cut-offs do not reliably exclude heart failure in individuals with obesity.

Heart failure (HF) is a complex and progressive syndrome associated with high morbidity, mortality, impaired quality of life, and substantial healthcare costs. Globally, more than 55 million people live with HF, and prevalence is steadily rising, largely driven by population ageing, improved survival after cardiovascular events, and the increasing burden of comorbidities. While the prevalence of HF with reduced EF (HFrEF) appears to be stable or declining, most likely due to improved treatment of ischaemic heart disease, HF with preserved EF (HFpEF) is steadily increasing and may become the most common form of HF in the future. Overall HF incidence has remained stable or even declined in many Western countries, although rising trends have been reported in younger populations and in specific regions. However, incidence of HFpEF is rising rapidly and has nearly doubled over two decades due to ageing and increased prevalence of comorbidities, whereas HFrEF incidence has declined slightly. Considerable geographic variation exists in HF epidemiology, with data from low- and middle-income countries being still limited, although HF in these settings often differs in terms of causes, age at onset, and outcomes. Despite substantial advances in life-saving, evidence-based therapies, prognosis remains poor: depending on the population and care setting 1-year mortality ranges from 5% to 34%, 1-year rehospitalization is ∼30%, and non-cardiovascular mortality is rising, particularly among patients with HFpEF. In this review, we provide an updated and comprehensive overview of HF epidemiology, summarizing recent evidence on prevalence, incidence, aetiologies, outcomes, and costs across diverse populations and regions worldwide.

Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia worldwide and is strongly associated with increased risks of stroke, heart failure, and mortality. Traditional methods to predict AF and prognostic its associated risks often fail to capture the full complexity of AF patterns, limiting their predictive accuracy. In spite of the improvements achieved by machine learning (ML) techniques, state-of-the-art AF-focused predictors do not generally incorporate longitudinal data, reducing their capacity to model the dynamic and evolving nature of individual behaviors and physiological indicators over time. The absence of a longitudinal perspective restricts understanding of how AF risk develops and changes across prognostic windows. This study addresses these limitations by developing superior ML models tailored to predict adverse events within a longitudinal Portuguese cohort of individuals with AF. The work targets six clinical endpoints: stroke, all-cause death, cardiovascular death, heart failure hospitalizations, inpatient visits, and acute coronary syndrome. The predictors yielded an AUC of 0.65 for 1- year stroke prediction, outperforming CHA ₂ DS ₂ -VASc (0.59). For all-cause mortality prediction, the models achieved an AUC of 0.78 against the 0.72 reference of GARFIELD-AF. In addition to predictive advances, the study identifies determinants of AF-related risks and introduces a prototype decision-support tool for clinical use.