Management of heart failure in general practice has been hampered by difficulties in diagnosing the condition and by perceived difficulties in starting and monitoring treatment in the community. Nevertheless, improved access to diagnostic testing and increased confidence in the safety of treatment should help to improve the primary care management of heart failure. With improved survival and reduced admission rates (achieved by effective treatment) and a reduction in numbers of hospital beds, the community management of heart failure is likely to become increasingly important and the role of general practitioners even more crucial.
Heart failure affects at least 20 patients on the average general practitioner's list
Diagnostic accuracy
Heart failure is a difficult condition to diagnose clinically, and hence many patients thought to have heart failure by their general practitioners may not have any demonstrable abnormality of cardiac function on objective testing.
A study from Finland reported that only 32% of patients suspected of having heart failure by primary care doctors had definite heart failure (as determined by a clinical and radiographic scoring system). A recent study in the United Kingdom showed that only 29% of 122 patients referred to a “rapid access” clinic with a new diagnosis of heart failure fully met the definition of heart failure approved by the European Society of Cardiology—that is, appropriate symptoms, objective evidence of cardiac dysfunction, and response to treatment if doubt remained.
Similar findings have been reported in the echocardiographic heart of England screening (ECHOES) study, in which only about 22% of the patients with a diagnosis of heart failure in their general practice records had definite impairment of left ventricular systolic function on echocardiography, with a further 16% having borderline impairment. In addition, 23% had atrial fibrillation, with over half of these patients having normal left ventricular systolic contraction. Finally, a minority of patients may have clinical heart failure with normal systolic contraction and abnormal diastolic function; management of such patients with diastolic dysfunction is very different from those with impaired systolic function.
Open access echocardiography and diagnosis
Owing to the non-invasive nature of echocardiography, its high acceptability to patients, and its usefulness in assessing ventricular size and function, as well as valvar heart disease, many general practitioners now want direct access to echocardiography services for their patients. Although open access echocardiography services are available in some districts in Britain, many specialists still have reservations about introducing such services because of financial and staffing issues and concern that general practitioners would have difficulty interpreting technical reports. The cost of echocardiography (£50 to £70 per patient) is relatively small, however, compared with the cost of expensive treatment for heart failure that may not be needed. The cost is also small compared with the costs of hospital admission, which may be avoided by appropriate, early treatment of heart failure.
Recent studies have shown that with appropriate education of general practitioners the workload of an open access echocardiography service can be manageable
Open access services have proved popular and are likely to become even more common; indeed, echocardiographic screening of patients in the high risk categories may well be justified and cost effective
One approach may be to refer only patients with abnormal baseline investigations as heart failure is unlikely if the electrocardiogram and chest x ray examination are normal and there are no predisposing factors for heart failure—for example, previous myocardial infarction, angina, hypertension, and diabetes mellitus. Requiring general practitioners to perform electrocardiography and arrange chest radiography, as a complement to careful assessment of the risk factors for heart failure, is likely to reduce substantially the number of inappropriate referrals to an open access echocardiography service.
Role of natriuretic peptides
Given the difficulties in diagnosing heart failure on clinical grounds alone, and current limited access to echocardiography and specialist assessment, the possibility of using a blood test in general practice to diagnose heart failure is appealing. Determining plasma concentrations of brain natriuretic peptide, a hormone found at an increased level in patients with left ventricular systolic dysfunction, may be one option. Such a blood test has the potential to screen out patients in whom heart failure is extremely unlikely and identify those in whom the probability of heart failure is high—for example, in patients with suspected heart failure who have low plasma concentrations of brain natriuretic peptide, the heart is unlikely to be the cause of the symptoms, whereas those who have higher concentrations warrant further assessment.
Sensitivity and specificity of brain natriuretic peptides in diagnosis of heart failure
| New diagnosis of heart failure (primary care) | Left ventricular systolic dysfunction | |
|---|---|---|
| Sensitivity | 97% | 77% |
| Specificity | 84% | 87% |
| Positive predictive value | 70% | 16% |
Primarypreventionandearlydetection
General practitioners have a vital role in the early detection and treatment of the main risk factors for heart failure—namely, hypertension and ischaemic heart disease—and other cardiovascular risk factors, such as smoking and hyperlipidaemia. The Framingham study has shown a decline in hypertension as a risk factor for heart failure over the years, which probably reflects improvements in treatment. Ischaemic heart disease, however, remains very common. Aspirin, β blockers, and lipid lowering treatment, as well as smoking cessation, can reduce progression to myocardial infarction in patients with angina, and β blockers may also reduce ischaemic left ventricular dysfunction. Early detection of left ventricular dysfunction in “high risk” asymptomatic patients—for example, those who have already had a myocardial infarction or who have hypertension or atrial fibrillation—and treatment with angiotensin converting enzyme inhibitors can minimise the progression to symptomatic heart failure.
Starting angiotensin converting enzyme inhibitors in chronic heart failure in general practice
Measure blood pressure and determine electrolytes and creatinine concentrations before treatment
Consider referring “high risk” patients to hospital for assessment and supervised start of treatment
Angiotensin converting enzyme inhibitors should be used with some caution in patients with severe peripheral vascular disease because of the possible association with atherosclerotic renal artery stenosis
Doses should be gradually increased over two to three weeks, aiming to reach the doses used in large clinical trials
Blood pressure and electrolytes or renal chemistry should be monitored after start of treatment, initially at one week then less frequently depending on the patient and any abnormalities detected
Startingandmonitoringdrugtreatment
Both hospital doctors and general practitioners used to be concerned about the initiation of angiotensin converting enzyme inhibitors outside hospital. It is now accepted, however, that most patients with heart failure can safely be established on such treatment without needing hospital admission. The previous concern—over first dose hypotension—was heightened by the initial experience of large doses of captopril, especially in those with severe heart failure, who are at greater risk of problems. Patients with mild or moderate heart failure, who have normal renal function and a systolic blood pressure over 100 mm Hg and who have stopped taking diuretics for at least 24 hours rarely have problems, especially if the first dose of an angiotensin converting enzyme inhibitor is taken at night, before going to bed.
Conditions indicating that referral to a specialist is necessary
Diagnosis in doubt or when specialist investigation and management may help
Significant murmurs and valvar heart disease
Arrhythmias—for example, atrial fibrillation
Secondary causes—for example, thyroid disease
Severe left ventricular impairment—for example, ejection fraction <20%
Pre-existing (or developing) metabolic abnormalities—for example, hyponatraemia (sodium <130 mmol/l) and renal impairment
Severe associated vascular disease—for example, caution with angiotensin converting enzyme inhibitors in case of coexisting renovascular disease
Relative hypotension (systolic blood pressure <100 mm Hg before starting angiotensin converting enzyme inhibitors)
Poor response to treatment
Heart failure clinics
Dedicated heart failure clinics within general practices, run by a doctor or nurse with an interest in the subject, have the potential to improve the care of patients with the condition, as they have for other chronic conditions, such as diabetes.
Blood should be taken for electrolytes and renal chemistry at least every 12 months, but more frequently in new cases and when drug treatment has been changed or results have been abnormal. The clinics should be used to educate patients about their condition, particularly in relation to their treatment, with messages being reinforced and drug treatment simplified and rationalised where appropriate. Patients whose condition is deteriorating may be referred for specialist opinion.
Examples of topics for audit of heart failure management in general practice
Means of diagnosis
Has left ventricular function been assessed, by echocardiography or other means?
Appropriateness of treatment
Are all appropriate patients taking angiotensin converting enzyme inhibitors (unless there is a documented contraindication)? Have doses been increased where possible to those used in the large clinical trials?
Monitoring treatment
Were blood pressure and renal function recorded before and after start of angiotensin converting enzyme inhibitors, and at intervals subsequently?
Variables that should be monitored in patients with established heart failure comprise changes in symptoms and severity (New York Heart Association classification); weight; blood pressure; and signs of fluid retention or excessive diuresis.
Impact of heart failure on the community
After a patient is diagnosed as having heart failure, substantial monitoring by the general practitioner is required. In our survey of heart failure in three general practices from the west of Birmingham, 44% of general practice consultations (average 2.6 visits per patient) took place within three months of the first diagnosis of heart failure, 23% were at three to six months (1.4 visits per patient), and 33% were at six to 12 months (2.0 visits per patient). Such management requires regular supervision and audit.
Relevance to hospital practice
In our survey of acute hospital admissions of patients with heart failure to a city centre hospital, the median duration of stay was 8 (range 1-96) days, with 20% inpatient mortality. Clinical variables associated with an adverse prognosis include the presence of atrial fibrillation, poor exercise tolerance, electrolyte abnormalities, and the presence of coronary artery disease. Angiotensin converting enzyme inhibitors were prescribed in only 51% of heart failure patients on discharge; after the first diagnosis of heart failure, the average number of hospital attendances (inpatient and outpatient) in the first 12 months was 3.2 visits per patient, with an average of 6.0 general practice consultations per patient. However, 44% of hospital attendances (1.4 visits per patient) took place within three months of diagnosis, 33% were at three to six months (1.0 visits per patient), and 23% were at 6-12 months (0.74 visits per patient).
Causes of readmission in patients with heart failure
Angina
Infections
Arrhythmias
Poor compliance
Inadequate drug treatment
Iatrogenic factors
Inadequate discharge planning or follow up
Poor social support
Admissions with heart failure over six months to a district general hospital serving a multiracial population
| Presentation (%) | Associated medical history (%) |
|---|---|
| Pulmonary oedema (52) | Ischaemic heart disease (54) |
| Congestive heart failure, with fluid overload (32) | Hypertension (34) |
| Myocardial infarction and heart failure (9) | Valve disease (12); previous stroke (10) |
| Associated atrial fibrillation (29) | Diabetes mellitus (19); peripheral vascular disease (13); cardiomyopathy (1) |
Population of 300 000 (7451 admissions; 348 (5%) had heart failure (mean age 73 years)).
These figures represent the collective burden of heart failure on hospital practice. Indeed, about 200 000 people in the United Kingdom require admission to hospital for heart failure each year.
Specialist nurse support
The important role of nurses in the management of heart failure has been relatively neglected in Britain. In the United States the establishment of a nurse managed heart failure clinic in South Carolina resulted in a reduction in readmissions of 4% and in length of hospital stay of almost two days. In another North American study a comprehensive, multidisciplinary approach to heart failure management, including supervision by nurses, resulted in a significant (56%) reduction in readmissions and hospital stay, with a trend towards reduced mortality. Quality of life scores also improved in the intervention group. A more dramatic result was obtained in a study from Adelaide, Australia, where multidisciplinary intervention resulted in a 20% reduction in mortality.
Nurse management of heart failure has implications for the provision of care in patients with chronic heart failure, sharing the increasing burden of heart failure. Specialist nurses would provide advice, information, and support to patients with heart failure and to their families and would ensure that the best treatment is given. The potential benefits are substantial, with reduced hospital admission rates, improved quality of life, and lower costs.
Economic cost of heart failure to NHS in UK, 1990-1
| Total cost (£m) | % of total cost | |
|---|---|---|
| General practice visits | 8.3 | 2.5 |
| Referrals to hospital from general practice | 8.2 | 2.4 |
| Other outpatient attendances | 31.8 | 9.4 |
| Inpatient stay | 213.8 | 63.5 |
| Diagnostic tests | 45.6 | 13.5 |
| Drugs | 22.1 | 6.6 |
| Surgery | 7.2 | 2.1 |
| Total | 337.0 | 100 |
Key references
Eccles M, Freemantle N, Mason J, for the North of England Guideline Development Group. North of England evidence based development project: guideline for angiotensin converting enzyme inhibitors in primary care management of adults with symptomatic heart failure. BMJ 1998;316:1369-75.
Francis CM, Caruana L, Kearney P, Love M, Sutherland GR, Starkey IR, et al. Open access echocardiography in the management of heart failure in the community. BMJ 1995;310:634-6.
Lip GYH, Sarwar S, Ahmed I, Lee S, Kapoor V, Child D, et al. A survey of heart failure in general practice. The west Birmingham heart failure project. Eur J Gen Pract 1997;3:85-9.
Remes J, Miettinen H, Reunanen A, Pyorala K. Validity of clinical diagnosis of heart failure in primary health care. Eur Heart J 1991;12:315-21.
Rich MW, Beckham V, Wittenberg C, Leven CL, Freedland KE, Carney RM, et al. A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure. N Engl J Med 1995:333:1190-5.
Stewart S, Vandenbroek AJ, Pearson S, Horowitz JD. Prolonged beneficial effects of home-based intervention on unplanned readmissions and mortality among patients with congestive heart failure. Arch Intern Med 1999;159:257-61.
Economic considerations
With an increasingly elderly population, the prevalence of heart failure could have increased by as much as 70% by the year 2010. Heart failure currently accounts for 1-2% of total spending on health care in Europe and in the United States. In 1993 in the United Kingdom, heart failure cost the NHS £360m a year; the figure now is probably closer to £600m, equivalent to 1-2% of the total NHS budget, and hospital admissions account for 60-70% of this expenditure. Admissions for heart failure have been increasing and are expected to increase further. Preventing disease progression, hence reducing the frequency and duration of admissions, is therefore an important objective in the treatment of heart failure in the future.
Heart failure is likely to continue to become a major public health problem in the coming decades; new and better management strategies are necessary, including risk factor interventions, for patients at risk of developing heart failure
Figure.
Diagnostic algorithm for suspected heart failure in primary care. Based on guidance from the north of England evidence based guideline development project (see key references box)
Figure.
Strategies for preventing progression to symptomatic heart failure in high risk asymptomatic patients
Figure.
Cumulative survival curves from the Adelaide nurse intervention study: 18 month follow up (see Stewart et al, key references box at end of article)
Figure.
Role of specialist nurse in management of patients with heart failure
Acknowledgments
The table on sensitivity and specificity is based on information in Cowie et al (Lancet 1997;350:1349-53) and McDonagh et al (Lancet 1998;351:9-13). The table showing admissions with heart failure to a district general hospital is adapted with permission from Lip et al (Int J Clin Prac 1997;51: 223-7). The table showing the economic costs of heart failure is published with permission from McMurray et al (Eur Heart J 1993;14(suppl):133).
Footnotes
R C Davis is clinical research fellow and F D R Hobbs is professor in the department of primary care and general practice, University of Birmingham.
The ABC of heart failure is edited by C R Gibbs, M K Davies, and G Y H Lip. CRG is research fellow and GYHL is consultant cardiologist and reader in medicine in the university department of medicine and the department of cardiology, City Hospital, Birmingham; MKD is consultant cardiologist in the department of cardiology, Selly Oak Hospital, Birmingham. The series will be published as a book in the spring.