Heart failure (HF) is a nosological entity of slow, progressive and sometimes unpredictable course, characterized by clinical, structural and functional deterioration of the heart, resulting from increased diastolic filling pressures and inadequate cardiac output unable to meet the metabolic and energetic demands of the organism (1). Globally, HF is a public health problem (2) with more than 60 million people suffering from this condition (29% have mild, 19% moderate and 51% have severe HF) in 2017. It is more frequent in females (34.8 million cases) than in males (29.5 million cases) and in high-income countries (871.1 cases per 100,000 population) (3), in which it is estimated that 1–2% of people live with HF (4). In addition, HF is estimated to have a high burden of disease, high rates of mortality and re-hospitalizations, impaired quality of life, and a significant economic burden, particularly due to frequent readmissions with a median hospital stay of 8.5 days [interquartile range (IQR: 7.38–11 days)] exceeding costs of $39 billion annually for health care systems (5–7).

In recent decades, the prognosis of patients with HF has considerably improved mainly due to significant innovations in medical therapy with neuromodulatory drugs and the development of device engineering (8). The prevalence of HF is increasing but with the development of effective treatment the survival is longer (9). Nonetheless, despite optimal medical therapy, 5% of patients with HF will inevitably progress to more advanced stages of the disease (10), being predominantly refractory with more severe signs and symptoms, more frequent decompensations and re-hospitalizations, poor quality of life and survival of <25% at 1 year and <8% at 2 years after diagnosis (11). From a health economics perspective, although advanced HF (AHF) affects only 1% of the population with HF, its high frequency of re-hospitalizations generates a significant consumption of resources that account for 60% of care costs, especially when surgical interventions such as heart transplantation or the implantation of a mechanical ventricular assist device are indicated (12). Therefore, the Interagency Registry for Assisted Mechanical Circulation (INTERMACS) classification system is a useful strategy to meet the needs of patients who are not eligible for advanced therapies, optimizing and implementing management strategies that reduce the high symptomatic burden of AHF and improving the quality of life of these end-stage patients. This system allows for better patient selection, better prognosis and determines the urgency of intervention (13).

The incidence of AHF is 0.2% of the world population (14). In the U.S., it is estimated that 250,000–500,000 patients are refractory to maximized medical therapy (7). In low- and middle-income countries, the severity of HF varies between countries and regions, with a prevalence of AHF ranging from 30.1 to 56.4% at diagnosis (15). Africa and Asia are the regions with the most severe HF phenotypes and have the lowest rate of health insurance, medication and educational level (16). In Latin America and the Caribbean, the prevalence of AHF varies between countries; between 4 and 6% of patients in Colombia have AHF with an annual mortality rate of almost 75% (17), about 2% of HF cases in Chile are refractory (18), and in Peru, 61 patients with AHF were transplanted between March 2010 and February 2018, and 26.3% of these patients required some type of mechanical circulatory assistance for bridging to cardiac transplantation (19).

In recent years, there have been reports of an increase in cardiovascular risk factors and in the survival of patients with HF in Latin American and Caribbean countries (20, 21). However, there is still little epidemiological evidence on AHF in the Peruvian population, which is corroborated by a bibliometric study on cardiovascular health in Peru, in which the main publications are related to HF in clinical trials (22). This increases the need to know the clinical and epidemiological profile and the therapeutic management of AHF in Peru in order to provide scientific evidence that is useful in clinical practice. Information on AHF in the Peruvian population is necessary and will serve as scientific evidence for the evaluation and development of strategies to reduce mortality and morbidity rates in patients with this medical condition.

The present study will provide information on the epidemiological, clinical, therapeutic, and annual survival characteristics of patients diagnosed with AHF treated in hospitals with HF units in the city of Lima, Peru. Therefore, we seek to increase knowledge about the epidemiology and appropriate management of AHF in high resolution hospitals in Peru, which have a high demand for medical care and where patients do not have a palliative care program when they do not have therapeutic options.

However, patients with AHF should be properly defined and identified to facilitate the application of treatments such as cardiac transplantation or long-term mechanical circulatory support devices. In Peru, there is no scientific evidence describing the current panorama of AHF in the population. This means that physicians are not properly trained with the characteristics of the Peruvian population to identify patients who could be candidates for such therapies and to recognize the optimal time to refer them to more complex HF units. Therefore, a hospital registry of AHF in the network of hospitals with HF units in the country is necessary to know the incidence, prevalence, and prognostic implications of this pathology in the Peruvian population.

Among the strengths of the study is its multicenter character, which will help to obtain a representative sample of the population with the condition studied, increasing the external validity of the results. In addition, it will be the first study to examine the epidemiological characteristics of AHF in public hospitals in Peru, providing relevant information on these observable characteristics in the management of high complexity patients. On the other hand, among the limitations of the study, the study can only describe associations and not causality due to its observational design. AHF is an infrequent pathology that will generate a low number of patients to be included in the study and there could be errors in data collection when using medical records.

Currently, the coronavirus disease pandemic (COVID-19) has led to changes in the epidemiology and management of HF worldwide, with decreased hospital admissions, delayed emergency care, and increased risk of complications (25, 26). In addition, these changes extrapolate into barriers to research, especially in the conduct of studies that require extensive physical examination, primary data collection, and face-to-face follow-up of participants (27, 28). Despite the fact that the study will be conducted in a pandemic context and with limited access to hospital centers, it is a priority to have clinical-epidemiological information on AHF in high resolution hospital centers in Peru to help Peruvian cardiologists in the search for the optimal management of these patients.

MC-D: conceptualization, project administration, resources, investigation, supervision, methodology, writing—original draft, and writing—review and editing. RL, AH-V, and RV-F: investigation, methodology, writing—original draft, and writing—review and editing. All authors contributed to the article and approved the submitted version.

This protocol was self-funded by the authors.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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