Undertreatment of heart failure has high cost to patients

Editor—Chronic heart failure remains a serious public health problem. The diagnosis constitutes a high risk of morbidity and mortality, with a prognosis that is at least as bad as many forms of cancer. Despite this, a high proportion of people with symptoms and signs of chronic heart failure are undiagnosed, and of those who are, many are undertreated.¹ The evidence in support of treatment with angiotensin converting enzyme inhibitors, β blockers, and, most recently, spironolactone, is compelling.² It follows, therefore, that undertreatment of chronic heart failure is associated with an increased risk of death, and the failure of the health service effectively to manage this problem costs these patients dearly.

Mason et al analysed individual patient data from studies of left ventricular dysfunction to identify complications during test dose and titration phases.³ They concluded that angiotensin converting enzyme inhibitors could be safely introduced in primary care, with the proviso that patients at risk of adverse events—for example, patients with severe (New York Heart Association class IV) heart failure—be referred for hospital based initiation of treatment. We support the conclusions reached by Mason et al but wish to draw attention to several additional points. β Blockers and spironolactone offer additional benefits, over and above those of angiotensin converting enzyme inhibitors, yet the rates of prescription of β blockers and spironolactone are even lower than those of angiotensin converting enzyme inhibitors.⁴ The evidence in support of β blockers and spironolactone, although comparatively recent, has nevertheless been available for more than a year.⁴ The initiation of β blockers and spironolactone in chronic heart failure requires assiduous care. The management of patients with chronic heart failure in the community therefore remains difficult. We investigated one possible solution to this in a randomised, controlled trial of a community based intervention programme led by a nurse specialising in chronic heart failure compared with usual care.⁵ In this study, nurse intervention included home visits, checking drug treatments and blood chemistry, and liaising with general practitioners and hospital based physicians. Nurse led intervention reduced hospital admissions and improved compliance compared with standard care. A similar programme has now been instituted in greater Glasgow.

All patients with a new diagnosis of chronic heart failure should, in the first instance, be referred for specialist outpatient care, in keeping with current management guidelines.¹ Intervention programmes led by specialist nurses may be one additional mechanism for optimising the further management of these patients in the community.