Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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The Creation of a Thousand Forests is in One Acorn.
- BM Hegde (19 August 2005)
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Cardiac Impairment or Heart Failure: What about 'Cardiovascular Insufficiency Syndrome' (CIS)
- J David Mitchell (19 August 2005)
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Cardiac Weakness
- James A Dickinson (22 August 2005)
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Heart Failure…Have a change of Heart?
- Chandrakant Madgaonkar (24 August 2005)
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Do we need new terminology to replace heart failure?
- Munir E Nassar, M.D. (24 August 2005)
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change the name
- Dr.P.D. Gokhale (24 August 2005)
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Re: change the name and knock-on effects
- Catie Gilbert (25 August 2005)
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Impairment is a continuum, not more descriptive or less confusing, however less alarming
- Atef Michael (29 August 2005)
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what do patients really think?
- Kate H. Field, Ann McPherson (30 August 2005)
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Cardiac Impairment or Deferred Success?
- Bernard A Foëx, Simon Carley (1 September 2005)
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Why does the official name need to be changed?
- Onisillos Sekkides (1 September 2005)
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Time to care?
- Jonathan Silcock (2 September 2005)
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It takes more than BNP to diagnose heart failure
- Miles D Witham, Tom P Fahey, Allan D Struthers (5 September 2005)
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What’s in a name…? A lot, it would seem
- Marilyn Kendall, Kirsty Boyd, Aziz Sheikh, Scott A Murray (6 September 2005)
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Heart Failure - A Paradox
- Chandrakant Madgaonkar (7 September 2005)
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heart failure is terminal
- M.Justin S. Zaman (8 September 2005)
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Hearts in a state of deferred success?
- R K Mohindra (11 September 2005)
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Further comments to support time honored heart failure terminology.
- Munir E Nassar, M.D. (12 September 2005)
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Cardiac impairment or heart failure, and natriuretic peptides.
- John S Harrop, Steven Burn, John Ashcroft (12 September 2005)
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Who cares what it's called? What do patients want and need?
- Iain Lawrie, Suzanne Kite, Miriam Johnson (13 September 2005)
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It's already cardiac insufficiency in the German-speaking world
- David A.C. Maclachlan (14 September 2005)
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Response to Dr Lawrie and colleagues, BMJ 13 Sept., 2005
- Munir E Nassar, M.D. (14 September 2005)
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In response to the responses
- Richard Lehman, Jenny Doust, Paul Glasziou (19 September 2005)
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Even cardiologists do not agree on what is heart failure
- Dr L B Tan (3 October 2005)
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BM Hegde, Retired Vice Chancellor Mangalore-575 004, India
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Dear Editor, Chronic heart failure, better labelled cardiac impairment, is not a disease and is a multi-system syndrome which starts almost from the time the cardiac output falls for any reason. The first organ to feel the pinch is the skeletal muscle, where, initially under undue exertion and later under usual exertion, anaerobic metabolism takes place producing anion collection inside the muscle cells, only to be relieved when the patient takes rest in the initial stages. When the muscle cells become hypertonic with anions compared to the extra cellular fluid water seeps into the muscle cells through osmosis making the cells swell. The swollen muscle cells trigger the intracellular pain fibres to give rise to muscle cramps, at times. The resultant increase in the osmolality of the extra cellular fluid (as water has seeped into the muscle cell) stimulates the posterior pituitary to secrete the anti-diuretic hormone. This is the beginning of the end and the end of the beginning of all that there is to cardiac impairment physiology. Consequently, the extra cellular fluid in the blood vessel becomes hypotonic stimulating the aldosterone system in the kidneys to later give rise to oedma etc. Still later the renal blood flow decreases as the cardiac output further goes down resulting in the vicious cycle of mouth eating the tail business! Hence all through the course of cardiac impairment the heart shows its power on the skeletal muscle indirectly stimulating the posterior pituitary.The key to chronic cardiac impairment saga is held by the skeletal muscle. Cardiac impairment is not only the cardiologist's cup of tea. The ejection fraction is a very poor cousin of other tests like BNP for the simple reason that the EF is not even the sole representative of the ventricular function. Some of it depends on the after load and preload, which, in turn, depend on the human mind! yours ever, bmhegde Competing interests: None declared |
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J David Mitchell, Researcher in Health and Medical Sociology Division of Primary Care, University of Liverpool, L69 3GB, UK
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To the Editor, As a humble, non-clinical researcher currently engaged in a qualitative study of Emotions and Coping in Chronic Heart Failure I heartily welcome the authoritative contribution of Lehman and colleagues in opening a debate about the label 'heart failure'. As part of the background work to my study I have explored and highlighted many of the issues to which they refer. Indeed, within the last week or so, I have attended a meeting with a group of general practitioners at which the issues of doctor-patient communication and the use of the term 'heart failure' were the dominant feature. Furthermore, I am developing a sense that not only does failure, for patients, mean the end of hope, as the authors suggest, but it also carries pejorative connotations of culpability, particularly against the prevailing public health and health promotion background which emphasises behaviour and lifestyle in the aetiology of heart disease. I, therefore, wholeheartedly support the call for a change in label in heart failure, and to this debate I offer the following perspective. There are many ways of viewing the complexity of heart failure, depending on training and professional experience. The physiologist in my multidisciplinary background identifies one common component across varieties of heart failure as the inability of the cardiovascular system, as a whole, to maintain an adequate pressure gradient in the circulation. Obviously, many of the causes of this inability lie with the structure and function of the heart itself, but that is by no means the whole story. This has led me, in discussions with colleagues, and in local, in- house seminars and presentations in Liverpool, to propose that we should deflect the blame away from the heart by employing 'cardiovascular' as the first element of a revised nomenclature. I have suggested 'insufficiency' as a suitable generic term to cover the range of deficits in function of the system currently covered by the label heart failure. Finally, and perhaps obviously, is the observation that the variety and complexity of expressions of this condition suggest that it should be described as a syndrome. We therefore arrive at Cardiovascular Insufficiency Syndrome, a description which I submit is fairly accurate, reasonably comprehensive, and, importantly, can conveniently be abbreviated to a simple acronym, CIS. Contact for further discussion on the main issue, or any other element of the above, please, to jdavidm@liverpool.ac.uk. Competing interests: None declared |
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James A Dickinson, Professor of Family Medicine Dept of Family Medicine, University of Calgary. Alberta CanadaT2N 1M7
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If one of the criteria for a term is that it helps communicate to patients, then we must find a simpler term than "impairment". I prefer to use the term "weakness" which can assist discussion with patients about pumping and simple physiology. It helps people to understand that strengthening the heart through activity can help, as well as the various drug treatments we use. Pedants may argue that weakness is not strictly accurate when the cause is valvular disease, but it is for most patients we see, and my search of a thesaurus finds no better basic english term. Competing interests: None declared |
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Chandrakant Madgaonkar, Family Physician J C Nagar; Hubli-580020; India
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Dear Editor – Richard Lechman states in his Editorial, “Cardiac impairment or Heart Failure? (BMJ- 2005; 331: 415-416 – 20 August), “failure means the end of hope…may have damaging consequences, both psychologically and in terms of adherence of treatment….heart failure confuses doctors and patients and needs renaming”. This argument, if taken to its ultimate conclusion, is also applicable to well established terminologies and clinical situations such as renal failure, hepatic failure, multiple-organ failure, end-organ failure, etc. One can add on clinical procedures such as failed forceps, failed low-back surgery syndrome, etc. The point therefore is – should “failure” be restricted to “heart, cardiac, cardio-vascular”? Certainly, over the years, novel drugs, inventions, transplants, etc. have added “years to life”, but the ultimate “failure” of any organ is a stark reality of human existence. If in this “latent” journey of “beginning of the end and end of the beginning” (as said aptly by B M Hegde), the term “failure” connotes damaging consequences, then alternatives such as “impairment, insufficiency, weakness” etc. may be applicable to any “failing…..failure” organ. I hope the lid on Pandora’s Box is quite secure! Competing interests: None declared |
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Munir E Nassar, M.D., Retired Pittsford, NY 14534 USA
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After considering the editorial content of Fiona Godlee of the BMJ(1) and the paper of Dr Lehman(2), suggesting alternative terminology for heart failure, namely cardiac impairment and also another suggested term of decompensation of the cardiovascular system, I think that the new terminology falls short to explain the complex syndrome of heart failure. Impairment usually is used by neurologists and psychiatrists. Heart failure is a time honored diagnosis of a complex clinical pathophysiological state of the heart and cardiovascular system, that needs an understanding on the part of the clinician, of normal cardiac function, a good history and clinical examination without resorting to additional diagnostic testing such as ejection fraction, echocardiography, and BNP, though all the latter modern testing is important. Heart failure is an abnormality in cardiac function, which by itself does not really consider disease states, that caused the disturbed function, although these diseases are of paramount importance to delineate. Heart failure means inadeqaute delivery of oxygenated blood and nutrients to the organ systems of the body and therefore there is inadequate pumping pressure for perfusion purposes. Finally, BNP is not a reliable test in patients with emphysema, and in women and in the elderly. I found that informing patients that they have a weak heart allays their fear and imparts hope for improvement with medications. References: (1) Fiona Godlee, editor. BMJ 2005; 331 (20 August), doi: 10.113/bmj.3317514.0-F (2) Heart failure ? Lehman, R. BMJ 2005; 331; 415-416 (20 August), doi:10.1136/bmj.331.7514.415 Competing interests: None declared |
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Dr.P.D. Gokhale, Chief Physician,Tinplate hospital Jamshedpur-India-831003
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I have been asked by patients -if I have heart failure how am I able to move? This interpretation of the word failure is rightly as per usual usage. It also gives the impression to patients of hopelessness. This suggestion of change to cardiac impairment is to be supported. Competing interests: None declared |
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Catie Gilbert, clinical coder (and biomedical science student) NHS Trust
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As a clinical coder, can I mention that 'heart failure' is coded to the ICD-10 code I50.9; the description of this code includes 'heart failure, biventricular failure, and cardiac, heart or myocardial failure, not otherwise stated'. However, a diagnosis of 'heart impairment' with no further qualifying description sends coders to the code I51.9; the description of this code is 'heart disease, unspecified'. If a change of description of the condition is decided upon by clinicians, please would they consider informing their clinical coding departments of the change? If coding departments were not informed, the codes applied to the condition might well alter with the change of name, even though the condition itself stayed the same. Competing interests: None declared |
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Atef Michael, Specialist Registrar Queen's Hospital, Burton on Trent, DE15 0AR
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Dear Sir, Dr Richard Lehman and colleagues’ article is thought inducing. They considered the term “heart failure” not quantitative and confusing and they preferred “impairment”. However the term “Cardiac impairment” is as vague and blurred. It is not more descriptive or less confusing. Impairment also is a wide spectrum or continuum. It may be paradoxically not reflecting the seriousness of the diagnosis, especially in late stages of heart failure when the prognosis may be more serious than many malignancies. Whatever term is used doctors can avoid confusion by explaining that failure, like many things in life and in medicine, is a spectrum, and it does not mean the end. Also patients should be given the time and encouraged to ask and to air fears and concerns. Competing interests: None declared |
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Kate H. Field, Senior qualitative researcher, Dept Primary Care, University of Oxford OX3 7LF, Ann McPherson
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We were interested to read your editorial on the renaming of heart failure. We would agree from our research, that many patients do not understand what the term heart failure means. We feel it would be a shame to substitute the word ‘heart’ with cardiac and this may cause more confusion as many patients may not know what the word cardiac means. We interviewed 40 patients from around the country at different stages of heart failure and many of them discussed their confusion about the meaning of heart failure – several said that the word ‘failure’ was unhelpful. These interviews can be seen on www.dipex.org/heartfailure Before officially renaming, it might be helpful to have a wider debate about this and ask patients for their opinions. . Kate Field D.Phil (kate.field@dphpc.ox.ac.uk) Ann McPherson Competing interests: Research on heart failure 2003 for DIPEx, University of Oxford. |
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Bernard A Foëx, Consultant in Emergency Medicine and Critical Care Department of Emergency Medicine, Simon Carley
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Lehman et al rightly point out that the term “cardiac failure” is less than helpful. It confuses doctors and it demoralises patients. Cardiac impairment may be, as they suggest, “kinder, and more accurate”. It is still not quite in tune with the “politically correct” culture of the last couple of decades [1]. We would suggest a more appropriate, and current, term, “cardiac deferred success”. It really implies no blame to anyone: much better. Bernard A Foëx
1. Michel, T., The Guide to Politically Correct Cardiology. The Journal of Irreproducible Results, 1993. 39(6). Competing interests: None declared |
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Onisillos Sekkides, Content Editor, Medical Conditions Camden, NW1 7BY
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I must confess, I am confused by the need to officially rename this condition. If it is a matter of clearer communication with the patient, why not just use a short-hand term like "heart weakness", while leaving the official name unchanged? If it is the case that physicians are confused, then dare I suggest they return to their textbooks. Competing interests: None declared |
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Jonathan Silcock, Lecturer in Pharmacy School of Healthcare, University of Leeds, LS2 9UT
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I have recently conducted interviews with 21 patients and 19 healthcare professionals on the topic of heart failure self-management. The issue of heart failure terminology was important, not least because many patients with the diagnosis had never heard the words in order to form an opinion. However, whatever words are used a bigger issue seems to be the time needed to explain properly the impact of the diagnosis on the individual. So some sort of user-friendly shorthand may leave the patient less worried, but it won't ensure their active engagement in future care. A change in name shouldn't divert attention from the need to think critically about practice style and communication. Competing interests: None declared |
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Miles D Witham, Clinical Lecturer in Ageing and Health University of Dundee, Tom P Fahey, Allan D Struthers
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Editor, Lehman et al[1] dislike the term ‘heart failure’ and seem to suggest that ‘cardiac impairment’ would be better. There are indeed problems with the term heart failure, one of which is that when someone dies from cardiac arrest, newsreaders often report that they died of heart failure. However, the public might be even more confused if we change the name of their disease unless the new name was a clear improvement. In lay terms, cardiac impairment is little different from the current term which is used by many patients and their carers and does not represent a great step forward in clarity. Lehman et al also suggest that BNP should be used to diagnose ‘cardiac impairment’ rather than measures of Left Ventricular Systolic Dysfunction (LVSD). There are two major problems with this. Firstly, the causes of elevated BNP are heterogenous, including atrial fibrillation, valvular disease[2], left ventricular hypertrophy[3], pulmonary hypertension, renal impairment and myocardial ischaemia[4], as well as LVSD. If all of these became ‘cardiac impairment’, we would still have no name for the clinical entity of heart failure, which is diagnosed by typical symptoms and signs in the presence of structural heart disease[5]. Secondly, the evidence base for treating heart failure has been established in patients with LVSD proven by cardiac imaging. Whilst we recognise the need to extend the evidence base to broader patient groups including those with less severe or no LVSD, it will remain necessary to undertake cardiac imaging to delinate the subset of patients known to benefit from therapy. Similarly, patients with other causes of a high BNP require therapy tailored specifically to the underlying cause. Lumping all of these patients together into the category of ‘high BNP cardiac impairment’ does not advance our ability to provide rational therapy. Miles Witham
References 1. Lehman R, Doust J, Glasziou P. Cardiac impairment or heart failure? BMJ 2005; 331(7514):415-416. 2. Weber M, Arnold R, Rau M, Brandt R, Berkovitsch A, Mitrovic V et al. Relation of N-terminal pro-B-type natriuretic peptide to severity of valvular aortic stenosis. Am J Cardiol 2004; 94(6):740-745. 3. Hutcheon SD, Gillespie ND, Struthers AD, McMurdo ME. B-type natriuretic peptide in the diagnosis of cardiac disease in elderly day hospital patients. Age Ageing 2002; 31(4):295-301. 4. Struthers AD, Davies J. B-type natriuretic peptide: a simple new test to identify coronary artery disease? QJM 2005. 5. Remme WJ, Swedberg K. Guidelines for the diagnosis and treatment of chronic heart failure. Eur Heart J 2001; 22(17):1527-1560. Competing interests: None declared |
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Marilyn Kendall, Research Fellow Primary Palliative Care Research Group, University of Edinburgh EH8 9DX, Kirsty Boyd, Aziz Sheikh, Scott A Murray
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Editor - Dr Lehman and colleagues raise an important point in relation to the defining and labelling of heart failure.(1) The communication impasse they highlight, whereby patients and their family carers do not want to hear and clinicians do not want to use the term “heart failure” is one we recognise and which deeply concerns us. In a recent study we found a variety of terms being used by patients, carers and professionals, but rarely “heart failure”(2)
Box: Anthology of terms and explanations used for heart failure
We found that people generally had a poor understanding of the nature of their heart condition, treatment and prognosis. In comparison, most demonstrated a greater willingness and ability to discuss living with the variety of co-morbid conditions with which they had also been diagnosed. Professionals found it difficult to find the right words that conveyed the potential seriousness of the condition and yet did not distress patients. For people affected by cancer, the increasing confidence in naming the “C” word over recent years has allowed more open discussions and more genuine partnerships to develop between patients, family carers and health care staff, and so contributed to the improvements in care and support. Our data suggest that our inability to name or “out” heart failure may have contributed to the continuing marginalisation and disempowerment of these vulnerable patients and their carers. Unless and until this impasse can be broken, perhaps through the confident use and explanation of a more accurate and acceptable term, it will be difficult for people with heart failure to join together and mobilise to campaign for more effective care and support, and/or to engage in genuine discussion and partnership with their health and social care professionals. So much of what is now taken for granted in communicating with, and caring for, people affected by cancer follows from their ability to name their disease. “What’s in a name?” A lot, it would seem. 1 Lehman R, Doust J, Glasziou P. Cardiac impairment or heart failure? BMJ 2005; 331: 415-416. 2. Murray SA, Boyd K, Kendall M, Worth A, Benson TF, Clausen H. Dying of lung cancer or cardiac failure: prospective qualitative interview study of patients and their carers in the community. BMJ 2002;325: 929-32. Competing interests: None declared |
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Chandrakant Madgaonkar, Family Physician J C Nagar; Hubli-580020; India
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Dear Editor - In the midst of various views about ‘renaming’ article “Cardiac impairment or heart failure” (BMJ 2005;331:415-416 - 20 August), it was interesting to read the recent BBC news article titled “Public unaware on Heart Failure” (http://news.bbc.co.uk/go/pr/fr/- /2/hi/health/4196502.stm - 2005/08/30); which highlights the findings of the survey carried out by SHAPE (Study of Heart Failure Awareness and Perception in Europe). The survey reports, nearly 90% of 8,000 people surveyed in nine European countries had heard of heart failure….but had widespread misconceptions about heart failure. For instance, over two-thirds mistakenly thought heart failure patients live longer than patients with cancer and HIV….and a third of them wrongly thought heart failure was a normal consequence of getting older. Lead researcher of this survey, Prof. Willem Remme concludes, “ the low level awareness of heart failure that we found is shocking and is putting lives at risk…public are not likely to seek medical help early….we urge everyone to educate themselves about early signs that may mean risk of heart failure and see your doctor in good time”. In such a paradoxical situation, we certainly need concentrate more on our efforts to sensitize public about ‘heart failure’, about which majority have heard, but have serious misconceptions, rather than in reorienting its terminology. Competing interests: None declared |
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M.Justin S. Zaman, British Heart Foundation Research Fellow in Cardiovascular Epidemiology UCL Medical School
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I totally agree with the idea that 'heart failure' should be abolished as a term. I tend to use 'weak heart' or something similar as to me failure seems a terminal expression, something that needs urgent resuscitation. But the impetus for change needs to start at the undergraduate curriculum. You know what they say about old dogs and tricks... Competing interests: None declared |
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R K Mohindra, SpR Cardiology James Cook University Hospital, TS4 3BW
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The problem is that the label of heart failure can refer to many states. The fact the word "failure" may be unpalatable seems less relevant. I would hate to discover my heart suffering from a state of "deferred success"! Heart failure can refer to (1) a clinical syndrome (of which there are several e.g. systemic hypoperfusion, pulmonary oedema, right heart failure); (2) a physiological state (i.e if the heart fails to match cardiac input with cardiac output without initiating physiologic compensatory mechanisms such as left ventricular dilatation or hormonal responses); (3) the underlying patholgical process (e.g. left ventricular systolic dysfunction) or even; (4) the prognosis resulting from the underlying pathology. I would suggest that the key is to leave heart failure as a label for the clinical entity, qualified as appropriate. The other potential references will require different and qualified terms e.g. left ventricular systolic dysfunction together with quantification (e.g. mild, moderate or severe) for one causative pathology. I believe that BNP is a sensitive tool for detecting patients who have active physiological compensatory mechanisms and who might benefit from medical intervention. But it is far from clear that this group of patients should attract the label heart failure. A new term might need to be fashioned for this group. Competing interests: None declared |
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Munir E Nassar, M.D., Retired Pittsford, NY 14534 USA
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To the BMJ Editor: Reading the many responses on the subject leads me to conclude that perhaps, or is it at all possible that practising general practitioners and clinicians are not fully cognizant of the clinical pathophysiology of heart faiure that has prompted them to a new unfamiliar term of cardiac impairement instead? If the reason is that patients are confused by the diagnosis of heart failure, it is by itself a poor excuse to change the term. The disturbed cardiac function in heart failure (refer to my definition vid supra) is due, at the left venticular level, to failure of the compensatory mechanisms of Starling's Law of the heart for further hypertrophy and dilatation of the left venticular muscle wall resulting in inadequate pumping pressure to sustain a normal cardiac output. This is left ventricular systolic heart failure. Or, when the left ventricular wall is rigid due to certain diseases, impeding normal left ventricular filling is known as diastolic left ventricular failure. Another problem that may add to the clinical picture of pulmonary congestion, rales, distended neck neins, gallop rhythm, cardiomegaly, enlarged liver, and ankle edema, is dysynchronous electrical impulse delivery to the left ventricle and to the right ventricle. In conclusion, cardiac impairement with all due respect appears a poor choice of words for such a complex pathophysiology that is heart failure. Competing interests: None declared |
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John S Harrop, Consultant Chemical Pathologist Derby Pathology, Derby Hospitals NHS Foundation Trust, DE22 3NE, Steven Burn, John Ashcroft
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Dr Lehman1 may well be correct in his call to rename heart failure and many would share his optimism for the use of BNP in the future management of "heart impairment"; but what about the present? This simple blood test has enormous value in helping to exclude the diagnosis of heart failure, especially in those "difficult to manage groups"- the elderly, housebound, with comorbidities, and social deprivation. Having introduced the NT-pro BNP blood test across primary care in Southern Derbyshire in October 2004, our preliminary analysis2 indicates that this simple investigation a) provides quicker access for GPs and patients to diagnosis of heart failure, b) leads to improved patient management by GPs with more appropriate referrals for echocardiography, cardiolog, and appropriate medical outpatient services, c) provides cost efficiencies against investment made and d) may facilitate a reduction in echocardiography referral of up to 60%. (We note that the increase in referrals for echocardiography and waiting times as a result of the new GMS contract has been reversed following the introduction of NT-pro BNP, enabling a reduction in the longest waiting time for echocardiography from 15 weeks in September 2004 to 8 weeks in March 2005). However we are acutely aware that in many areas of the NHS GPs do not yet have any access to BNP. Hopefully reviews such as that by Dr Lehman, and local experiences such as ours, will make commissioners re- examine their purchasing decisions. 1. Lehman R, Doust J, Glasziou P. Cardiac Impairement or heart failure? BMJ 2005; 313: 415-6 2. Knowles S, Burn S, Cassidy M, Wood P, Mayne J, Docherty D, Harrop J. European Congress of Biochemistry and Laboratory Medicine – EuroMedLab 2005 Glasgow. Clin Chim Acta 2005; 355/S: S110-1 Competing interests: None declared |
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Iain Lawrie, Specialist Registrar in Palliative Medicine Palliative Care Team, The General Infirmary at Leeds, LS1 3EX, Suzanne Kite, Miriam Johnson
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Editor, We read with interest the editorial (and subsequent Rapid Responses) regarding perceived difficulties with the term ‘heart failure’ by Lehman et al.1 We agree that heart failure is both a subjective and an emotive term which doctors can be reluctant to use. However, it is more important that, whatever term is used, the term and it’s associated meanings should be recognisable to patients, their carers and health care professionals alike. There is evidence that people with heart failure have less understanding of their illness than in other chronic diseases2 and that they would welcome more information, especially regarding prognosis.3 What information and/or knowledge do patients with heart failure actually need and want? They need to know and understand, as far as they are able: what is wrong with them; to appreciate the importance of working in partnership with their clinicians and complying with treatment in order to achieve optimum function; to be able to discuss and understand their prognosis to have the opportunity for adequate end-of-life preparation; and to have access to the supportive care they need. The key factor to fulfilling these aims is surely effective communication. Much of the work in communication in medicine over the past forty years has been in the field of oncology and has focussed on such areas as breaking bad news, communication of risk and uncertainty and development of language which avoids euphemisms and enables honest but gentle discussion of their cancer. Many patients appear to welcome such an approach from professionals involved in their care,4 covering all aspects of their illness, both positive and negative. With heart failure, it may be that we can learn from the experience within oncology and realise that there are two main issues. First, the ‘label’ we attach to a disease and, second, how we communicate with and support our patients. Both the overly optimistic (‘your heart’s a bit weak’) and the safely opaque (‘cardiovascular insufficiency syndrome’!) may not really be helpful in the long run. We need our patients to tell us. Iain Lawrie, specialist registrar in palliative medicine
Suzanne Kite, consultant in palliative medicine
Miriam Johnson, consultant in palliative medicine
1. Lehman R, Doust J, Glasziou P. Cardiac impairment or heart failure? BMJ 2005;331: 415-6. 2. McCarthy M, Lay M, Addington-Hall JM. Dying from heart disease. JRCP (Lond) 1996; 30: 325-8. 3. Rogers AE, Addington-Hall JM, Abery AJ, McCoy ASM, Bulpitt C, Coats AJS, Gibbs JSR. Knowledge and communication difficulties for patients with chronic heart failure: qualitative study. BMJ 2000; 321: 605 -7. 4. Löfmark R, Nilstun T. Not if, but how: one way to talk to patients about forgoing life support. Postgrad Med J 2000; 76: 26-8. Competing interests: None declared |
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David A.C. Maclachlan, Consultant Physician and Rheumatologist CH 9410 Heiden, Switzerland
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In the German-speaking world, cardiac insufficiency (Herzinsuffizienz)is the preferred term. Cardiac failure (Herzversagen) implies a terminal event and thus usually appears only on death certificates. In the German version of ICD 10, I50.0 is congestive cardiac insufficiency (kongestive Herzinsuffizienz). Competing interests: None declared |
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Munir E Nassar, M.D., retired 17 Cobblefield Way, Pittsford, NY 14534 USA
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To the BMJ Editor: With all due respect, Dr. Lawrie and collegues' response to the debate over heart failure, that was started by Dr. Lehman is well taken. However, though it boils down to clear communication between physician and patient it is equally important to provide a correct diagnosis. Heart failure is a disturbed heart function (functional entity), as a result of pathologic disease entity be it due to leaky aortic valve, or myocardial infarction, or poorly controlled hypertension (space does not permit me to name all the diseases that if untreated end up in heart failure). It remains for the physician to explain to the patient that he has weak heart function caused by a specific disease and with specific treatment the condition may improve dramatically, but if untreated the end result is serious. It remains for the physician to offer to the patient the best available treatment for his disease and for the heart failure, be it medical/surgical, or including electrical synchronous stimulation of both ventricles if indicated. I am not convinced that it is necessary to change the diagnosis of heart failure to a different name? Competing interests: None declared |
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Richard Lehman, General Practitioner Hightown Surgery. Hightown Gardens, Banbury, OX16 9DB, Jenny Doust, Paul Glasziou
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Editor, Our editorial made two points – that the term “heart failure” is unsatisfactory, and that B-type natriuretic peptide should be used to define and monitor cardiac impairment. These points are interconnected, but we can begin by separating them. Naming a syndrome serves two purposes, which may be mutually exclusive. One is to achieve greater clinical accuracy, and the other is to help patient understanding. For example, “chronic obstructive pulmonary disease” is more accurate than older terminology such as “chronic bronchitis”, but it is useless as a communication tool with patients, so we use expressions like “smoking related lung damage”. There is no doubt, as several correspondents point out, that the term “heart failure” is widely misinterpreted by patients, and there is evidence that it may do harm (1). Dr Michael suggests that “impairment” covers a wide spectrum and may be just as confusing and alarming as “failure”. We agree on the first point – we want to cover a wide spectrum. We disagree that “impairment” is commonly used in the same sense as “failure”. When a car is impaired, it can be driven, but it needs to go to a garage: when a car fails, it needs to be towed away, perhaps to the breaker’s yard. When we speak of “renal impairment”, we mean a condition that needs monitoring and may need treatment: “renal failure”, on the other hand, usually implies the need for dialysis or transplantation. When the term “heart failure” was first coined, it may have been appropriate, but the spectrum of impairment it is now used to cover is much broader, and it has become inappropriate in most contexts. Accepting that “heart failure” is unhelpful as an aid to patient communication, should we nonetheless retain it for its scientific value? There is, after all, an immense literature and several societies and journals which include the name. We agree that the term “Cardiovascular Insufficiency Syndrome”, proposed by Mitchell, has the advantages of greater accuracy and emphasis on the role of the whole circulation, rather than just the heart, in this complex syndrome. Whether medicine should be encouraged to welcome another abbreviation – CIS- into its ranks is another matter. This brings us to the points raised in the letter from Witham et al. The European Society of Cardiology definition of heart failure to which they refer does not specify evidence of “structural heart disease” but “objective evidence of cardiac dysfunction at rest”(2). We would argue that sustained elevation of BNP constitutes such evidence. We did not intend to suggest that this alone would define clinical heart failure or cardiac impairment, without the presence of symptoms (as in the ESC definition). But elevation of BNP should always lead to further investigation, as Struthers has recently proposed (3). Raised BNP would lead us to diagnose many varieties of CIS or cardiac impairment, each requiring individualised treatment – including those mentioned by Witham, such as atrial fibrillation, valvular disease, and cardiac strain associated with renal disease. In 1994 Struthers et al. (4) found that BNP was more predictive than the systolic ejection fraction in predicting outcome following myocardial infarction. Eleven years later, we remain imprisoned by an evidence base for treating “heart failure” which informs us about little except the average effect of polypharmacy in everyone with a lowered ejection fraction. If measurement of BNP is a good surrogate marker for monitoring treatment in a wide range of conditions giving rise to cardiac impairment, then we have a new research agenda which goes much wider than the traditional one of adding new treatments to old in patients admitted to hospital and found to have low ejection fractions. Not only does this hold out the promise of individualised treatment for many different kinds of cardiovascular impairment, it may also be the path to prevention of overt “failure” in many patients with presymptomatic disease. Richard Lehman
References: 1. Tayler M, Ogden J. Doctors’ use of euphemisms and their impact on patients’ beliefs about health: an experimental study of heart failure. Paient Educ Couns 2005;57:321-6 2. Remme WJ, Swedberg K. Guidelines for the diagnosis and treatment of chronic heart failure. Eur Heart J 2001;22:1527-1560 3. Struthers AD, Davies J. B-type natriuretic peptide: a simple new test to identify coronary artery disease? QJM 2005 Aug 22 (Epub ahead of print) 4. Choy AM, Darbar D, Lang CC et al. Detection of left ventricular dysfunction after myocardial infarction: comparison of clinical, echocardiographic, and neurohormonal methods. Br Heart J 1994;72:16-22 Competing interests: None declared |
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Dr L B Tan, Consultant Cardiologist Leeds General Infirmary, Leeds, LS1 3EX, UK
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Dear Sir I seem to have arrived rather late at this discussion, but there are still a few important points that have not been aired so far. (i) It is a pie in the sky to find any medical term that patients will not somehow get confused with. However, before we get too condescending, a recent survey of so-called world "experts" came to the conclusion that 'Heart failure is the label for a cardiovascular syndrome that is lacking uniform criteria for definition' [1]. The simple reason is this: cardiologists and world experts do not really know how best to measure cardiac function and dysfunction to determine the extent of failure. When we ask renal or chest physicians, they know exactly what to measure (e.g. serum creatinine, blood gases, etc) to decide which patients need dialysis or artificial ventilation. These are DIRECT measures of organ function, and there is no counterpart in standard cardiological practice. What figures (e.g. LVEF, BNP, VO2max) do cardiologists rely on to decide which patients require cardiac transplantation or assist devices, and are these reliable? (ii) Many papers and guidelines published in this area confuse the term "definition" with "diagnosis" of heart failure. Vagueness in definition leads to misleading diagnoses resulting in inappropriate treatment regimen. Quibbling about how patients construe the terms "heart failure" or "cardiac impairment" should not detract from the more urgent matter that heart failure specialists should put their house in order first by finding an agreed correct definition. There are real problems in available definitions of heart failure [2]. (iii) In medical semantics, quite often the commonly acknowledged meaning attached to a term evolved through usage and time overrides the correctness of the term itself. For example, 'arrhythmia' used by medics does not mean the absence of rhythm (cf. akinesia) but some disorder in rhythm, which should have been more correctly referred to as 'dysrhythmia'. Heart failure as commonly used by clinicians therefore includes partial failure, and not necessarily total cessation of pump function. (iv) Moreover, in medicine, when the mechanisms of disease are unknown, we describe the condition as a syndrome, but when the mechanisms and methods of measurement become unravelled, we employ more definitive descriptions. The fact that heart failure is still defined as a Syndrome rather suggests the stage of our medical knowledge (or lack of). (v) It has been my standard teaching to medical students and junior doctors that the term "heart failure" should never be communicated without qualifying its aetiology and severity. The qualifying terms may include weakness or scarring of heart muscle, or leaky valves, or electrical rhythm or conduction problems, which are words that lay persons can understand. (vi) We have recently published that BNP is a good indirect biomarker of cardiac dysfunction [3-6], and it is an indictment of NHS backwardness in the UK that this test is not generally available to all clinicians caring for heart failure patients. However, clinicians should also be aware that BNP levels can be altered by factors other than heart failure and correct interpretations of results are crucial. It is clear that this debate is not just about semantics, but it has exposed the crux of the matter – fundamentally there is a gaping hole in our knowledge of what heart failure really is that we have so far miserably failed to define and measure it. Dr L B Tan REFERENCES: 1. Coronel R, de Groot JR, van Lieshout JJ. Defining heart failure. Cardiovasc Res 2001 Jun; 50(3):419-22. 2. Tan LB, Al-Timman JK, Marshall P, Cooke GA. Heart failure: can it be defined? Europ J Clin Pharm 1996; 49 (Suppl 1):S11-8. 3. Williams SG, Ng LL, O’Brien R, Barker D, Li YF, Tan LB. Use of BNP to rule out the diagnosis of heart failure depends on the selection of cut-off value. Heart 2005; 91:1090–91. 4. Williams SG, Ng LL, O’Brien R, Taylor S, Wright DJ, Li YF, Tan LB. Complementary roles of simple variables, NYHA and N-BNP, in indicating aerobic capacity and severity of heart failure. Int J Cardiol. 2005 Jul 10; 102(2):279-86. 5. Williams SG, Ng LL, O'Brien R, Taylor S, Wright DJ, Tan LB. Is plasma N-BNP a good indicator of the Functional REServe of failing Hearts? The FRESH-BNP study. Eur J Heart Failure 2004; 6(7):891-900. 6. Williams SG, Ng LL, O’Brien R, Taylor S, Li YF, Tan LB. Comparison of the plasma N-brain natriuretic peptide, peak oxygen consumption, and left ventricular ejection fraction for severity of chronic heart failure. Am J Cardiol 2004; 93:1560–1. Competing interests: None declared |
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