How long before hospital admission do the symptoms of heart failure decompensation arise?

ABSTRACT Objective: to identify the signs and symptoms of decompensation of heart failure (HF) and the duration of time to hospital admission. Method: this is a cross-sectional study with adult patients hospitalized for decompensated HF in a teaching hospital located in southern Brazil from July to October 2017. Data collection was performed through a structured questionnaire that included sociodemographic, clinical signs and symptoms of HF. In the data analysis, the following tests were applied: t-Student, Mann Whitney U-Test, Chi-Square Tests. Results: 94 patients, aged between 42 and 98 years old (mean of 71.2 years old) were included. The most prevalent signs and symptoms before emergency admission were dyspnea (79.8%), cough (29.8%), orthopnea (27.7%), edema (23.4%), and fatigue (22.3%). The median time from onset of signs and symptoms to arrival in the emergency room is fatigue and edema 7 days, orthopnea 5 days, cough 4 days and dyspnea 3 days. Conclusion: the set of classic signs and symptoms of decompensation of HF occurs around seven days before the emergency search and dyspnea is the worsening that leads the patient to a hospital emergency.


Introduction
Heart failure (HF) has been a serious and progressive public health problem, leading to an increase in hospital readmissions, a risk of early mortality, a significant impact on the quality of life of patients, and an important source of high costs for the health system, whose elderly population is growing (1)(2) . It is characterized as one of the main causes of hospitalization in adults, the first cause of hospitalization in elderly patients (3)(4) , and the main cause of rehospitalization according to the Brazilian Registry of Acute Heart Failure (BREATHE), study that outlined the scenario of HF in Brazil (5) . The reasons occur specifically by three factors: population aging; increased incidence of precursor diseases such as systemic arterial hypertension (SAH), obesity, diabetes mellitus (DM); and improved therapeutics in several cardiac disorders such as acute myocardial infarction (AMI) and valvulopathies, which allows an increase in the survival of these patients, who eventually develop HF over the years (5) .
Although the advances in optimal clinical and therapeutic management have been observed, HF remains a challenge for the health team, resulting in physical and psychological suffering (2) , caused by the lack of knowledge of non-pharmacological measures, inadequate adherence to medication treatment, and by the inability to identify and interpret the signs and symptoms of disease decompensation (4)(5)(6) .
Patients hospitalized for acutely decompensated HF had until recently a poor prognosis, but better identification of symptoms and therefore more appropriate treatments led to a 40-50% reduction in mortality in a short period of time. Therefore, nursing actions aimed at educating patients and their families for the early recognition of signs and symptoms, indicators of worsening, are important to seek immediate medical attention without the loss of critical time, hours or even before adequate treatment (5) .
It is known that the late recognition of these clinical manifestations is associated with an increase in rates of hospitalizations and complications, mainly including mortality. About two-thirds of these acute events occur in patients with known HF, and about one third is the first event in individuals without the diagnosis of HF (7)(8) .
Incomplete understanding of the process of identification, interpretation of signs and symptoms of HF, and decision making by patients can be a barrier to the success of professional interventions aimed at effective self-care and prevention of readmission. Although some studies (9)(10)(11) have already evaluated patients' experiences, including how signs and symptoms were interpreted and managed before hospitalization, there is a gap in examining the time between the onset of these clinical manifestations and the search for a service emergency room. This study aims to explore the relationship between the duration of signs and symptoms that patients associate with worsening HF, being in their homes, before seeking health care in a hospital environment. The identification of the mean time of onset of the symptoms that lead the patients to seek an emergency service is a relevant data to compose the set of information that professionals must consider to offer interventions directed to the management of HF. A prevalence of 94% of dyspnea was estimated (12) , with a precision and significance of 5%, and the minimum number of participants was 87. In the period from July to October 2017, data collection was performed through a structured questionnaire that comprised sociodemographic, clinical data and signs and symptoms of HF. For sociodemographic characterization, age, gender, race, education level, marital status, employment status, and origin were Born MC, Azzolin KO, Souza EN. registered. A health plan, intensive care unit admission (ICU) and in-hospital mortality were found to characterize hospital admission. In the clinical profile, the time of illness and hospitalization in the last year for decompensated HF according to the patient's own report, presence of comorbidities, etiology and functional class of HF according to New York Heart Association (NYHA) criteria were identified (13) . Also, left ventricular ejection fraction (LVEF) was recorded according to the last echocardiogram, presence, and duration of signs and symptoms of HF experienced before hospital admission according to the patient's report.  (14) were respected.

Results
A total of 94 patients, aged between 42 and 98 years old, with a mean age of 71.2±13.4 years old,      Table 3 shows the relation of signs and symptoms and their duration before hospital admission reported by the patients.
The association between the most prevalent signs and symptoms before the admission to the emergency room and the health insurance, before the hospitalization in the last year and the ejection fraction was found to be a significant association between the presence of edema and previous hospitalization (p=0.047). Data is presented in Table 4.

Discussion
This study identified the occurrence of signs and symptoms of decompensated HF and the duration of time until the patient sought a hospital emergency service.
Regarding the occurrence of signs and symptoms before the hospital admission, the intensification of dyspnea was the most prevalent. This finding is in agreement with the other studies that proved to be the most important cause of readmission (1)(2)(3)(15)(16) . Other signs and symptoms were also evidenced in this study: cough, orthopnea, edema, and fatigue. Although these signs and symptoms appear with greater intensity before the search for hospital care, orthopnea is more characteristic for HF, since the others can also be found in other clinical conditions (17) . Data from the international literature point out the importance of recognizing HF symptoms, characterized as a complex phenomenon since patients present a variety of symptom combinations at different time intervals, charactered as a mixture of acute and chronic symptoms (18) .
Another study shows that the ability of patients to recognize, interpret and assess worsening symptoms of HF is limited. Suffering and intensification of symptoms such as dyspnoea, edema, and orthopnea are related to the greater delay in care. These delays in seeking care vary from hours to days from onset of symptoms to hospital admission (19) . The identification, tolerance, and decompensation of signs and symptoms caused these patients to seek hospital care within a period of up to seven days. These data are similar at the time of presenting symptoms before hospital admission (12,(20)(21) .
The mean duration of early symptoms of decompensated HF was one to nine days, but duration of dyspnea ranges from one to eight, 5 days before searching for service.
It is known that symptoms such as edema, weight gain, and fatigue are tolerated by patients with HF around seven days and dyspnea for three days before seeking a health service (9,22) . These data is similar to our results because the demand for care was within seven days for the clinical manifestations of worsening HF, and dyspnea in three days. It is inferred that the predominance of these symptoms can vary from 24 hours to two weeks, although most report the presence of the symptom of up to seven days, but there were cases in which the patient took more than 60 days to seek medical attention, the which may have aggravated their clinical condition, with a higher risk of severe complications, including death.
In our study, more than half of the patients hospitalized for decompensated HF were readmitted to the hospital in the last 12 months. This is similar to another study (23) , which showed that 60% are readmitted in 90 days. In the national registry of HF, a study called BREATHE, approximately half of all patients hospitalized with this diagnosis are readmitted within the first 90 days after hospital discharge, and this hospital readmission is considered a risk factor for death (5) .
Together with the high rates of readmissions, the high in-hospital mortality rate was 13.8% of patients admitted for HF decompensated in this study, higher than the mortality rate in the BREATHE registry (12.6%) (5) , and in the DATASUS records, which is 11.0% (24) . These data are more than twice that found in US and European  (8) .
with the signs and symptoms of decompensation of the CI at home until the search of care. It is important to mention that decision-making in seeking a health service is related not only to the identification and interpretation of signs and symptoms of worsening HF but also to external factors such as access to health services and professionals, previous experiences in terms of problem-solving in settings other than a hospital emergency, and the support resources patients have to travel to a health facility. The best management of HF is through an adequate understanding of the context of the patient to customize the educational interventions so the patient and the family feel engaged in the therapeutic plan.
As a limitation of this study, there were the behavior of variables not evaluated over time to infer causal relationships between them.

Conclusion
A set of signs and symptoms of HF decompensation, consisting of dyspnea, cough, orthopnea, edema, and fatigue in general, has been present for at least seven days before the search for health care. Among them, dyspnea is the most prevalent and decisive symptom for the patient to seek a hospital emergency service, taking approximately three days.
In this sense, the results can subsidize personalized educational interventions with the aim of helping patients and family members better manage the onset episodes of clinical manifestations of HF decompensation.