Intended for healthcare professionals

Letters

Author's reply

BMJ 1995; 311 doi: https://doi.org/10.1136/bmj.311.7000.327c (Published 29 July 1995) Cite this as: BMJ 1995;311:327
  1. John McMurray
  1. Consultant cardiologist Department of Cardiology, Western General Hospital, Edinburgh EH4 2XU

    EDITOR,--Laurence O'Toole and colleagues are missing the point. Rapid access and direct access services are complementary rather than mutually exclusive. A patient with suspected heart failure needs echocardiography, and rapid access to a specialist is not going to alter that. The clinical diagnosis in such patients is difficult for both specialists and generalists, as is borne out by the fact that O'Toole and colleagues found left ventricular impairment in only a quarter of their patients. Where our two approaches differ is in deciding whether specialist advice on management is needed. Our local general practitioners do not believe that all patients with heart failure need specialist management; they believe that, with guidelines, most patients with uncomplicated disease can be managed in the community. Direct access to diagnostic testing is not a problem if the condition sought can be managed by the doctor using the test, whether he or she is based in a hospital or in the community.

    Mark Wallace and Mark Levy believe that our conclusion was misleading. We actually said that a change in treatment was recommended in almost 70% of those patients who were already treated. We did obtain input from general practitioners at the design stage of our study. It is feasible to recommend changes in treatment on the basis of echocardiographic findings. Severe left ventricular dysfunction indicates that use of an angiotensin converting enzyme inhibitor should be considered; diuretic treatment should be reconsidered in obese patients with normal left ventricular function. Our recommendations were, however, only advisory, and the final decision on treatment was left to the general practitioner. Though only 93 out of about 550 general practitioners attended our launch meeting, one representative of virtually every practice in Edinburgh was present.

    Epidemiological surveys suggest that 1% of the population, or, in our area, 11000 patients, have heart failure. Many will already have been diagnosed and treated or referred to other hospitals in the area. It is therefore impossible to know how big an impact our service will have on heart failure. It is also difficult to comment on asymptomatic left ventricular dysfunction as the prevalence of this is unknown. We agree with David I Slovick, however, that many doctors in hospital and in the community do not appreciate the importance of heart failure and its treatment. With our echocardiography service we have shown to our local general practitioners, in a practical way, that we take this problem seriously.

    In response to Robert J MacFadyen and colleague's comments, the treatments we suggested stopping were diuretics and calcium channel antagonists, neither of which improve systolic function. While having grave doubts about the concept of heart failure with normal systolic function, we did not advise stopping a diuretic when there was a history of breathlessness and “congestion” (or if there was another indication). We agree that many patients with breathlessness and normal left ventricular systolic function have other important problems, which in our population are most commonly obesity, chronic lung disease, atrial fibrillation, and myocardial ischaemia manifest as breathlessness.

    Philip J G Kirby and Jeffrie R Strang are correct to point out that the “effectiveness” of our service depends on whether recommended changes in treatment are implemented by the general practitioner. While formal follow up has not yet been carried out, we are confident that one of the most important recommendations, to start treatment with an angiotensin converting enzyme inhibitor, was carried out because most general practitioners opted for such treatment to be started in hospital.

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