Taking heart failure seriouslyBMJ 2000; 321 doi: https://doi.org/10.1136/bmj.321.7269.1095 (Published 04 November 2000) Cite this as: BMJ 2000;321:1095
Diagnosis and initiation of treatment are the aspects to concentrate on
- John G F Cleland, professor of cardiology (, )
- Andrew Clark, senior lecturer,
- John L Caplin, consultant cardiologist
- Academic Department of Cardiology, Castle Hill Hospital, Kingston upon Hull HU16 5JQ
- Department of Cardiology, Hull Royal Infirmary, Kingston upon Hull HU3 2JZ
General practice p 1113
Heart failure is common, serious, and treatable, 1 2 so great efforts should be made to manage it correctly. In this issue Mason et al point out that fear of side effects may be a major barrier to the use of angiotensin converting enzyme inhibitors by general practitioners (p 1113).3 However, management is not just about prescribing the correct treatment; it also involves obtaining a proper diagnosis.
An estimated 10 million patients in Europe have heart failure secondary to left ventricular systolic dysfunction. 1 2 They are dwarfed by the estimated additional 40 million who have symptoms and signs of heart failure2 but in whom the diagnosis is subsequently refuted by investigation4 or attributed to another cause such as “diastolic” heart failure,2 a condition that is not known to respond to angiotensin converting enzyme inhibitors.5 Only once a diagnosis of heart failure has been established and underlying left ventricular systolic dysfunction confirmed is treatment with a combination of angiotensin converting enzyme inhibitors and β blockers (Cochrane reviews in preparation) generally appropriate.
Who then should manage patients with suspected or confirmed heart failure? The diagnostic burden of suspected heart failure is about 50 000 patients per million population, of which about 10 000 will have heart failure due to left ventricular systolic dysfunction.2 Any plan that hopes to manage patients with suspected heart failure properly must involve many healthcare workers.
Most cases of heart failure are diagnosed during a hospital admission—56% according to surveillance studies in UK general practice6 and 82% according to epidemiological data.7 Presentation is often acute and secondary to myocardial infarction or to atrial fibrillation. An average British district general hospital can expect to manage over 1000 deaths and discharges related to heart failure a year,8 and in many more cases the diagnosis will be suspected but refuted. In these cases diagnosis and initiation of treatment should be the responsibility of hospital doctors. Unfortunately, few patients are admitted under consultants with a specific interest in cardiovascular disease, and appropriate investigation or initiation of recommended treatment is often neglected.9 Primary care physicians have an important role in identifying and rectifying these omissions.
Many suspected cases of heart failure will be seen in primary care that require the diagnosis to be excluded. Investigations, such electrocardiography,10 measurement of natriuretic peptides11 and possibly even clinical acumen (despite evidence to the contrary1), may help identify patients at low risk of heart failure, but if symptoms persist these patients will probably eventually be referred for an echocardiogram. Moreover, patients identified by simple tests as likely to have heart failure need echocardiography to confirm the diagnosis and establish its probable cause.
Therefore echocardiography forms a focal point on which most patients with suspected heart failure will converge. In the UK echocardiography is usually carried out in hospital but elsewhere it is often performed in ambulatory polyclinics or by office based cardiologists. The need for training, quality control, professional stimulation, and cover for absences suggests that lone echocardiographers are unlikely to deliver a consistent, high quality, cost effective service. If echocardiography is best delivered by a department rather than an individual this implies that coordinated services covering relatively large populations are required. Once a coordinated approach to diagnosing heart failure in one place is accepted this provides an opportunity to build an effective system for the delivery of care around it, with protocols to ensure initiation, titration, and monitoring of therapy. This may be based in primary care, in hospital with community liaison nurses, or in new organisations such as large ambulatory facilities staffed by specialists in various disciplines (polyclinics).
Management of the side effects of therapy may also play a role in deciding how services should be planned. The SOLVD study data have been used to try to quantify the risk of side effects with ACE inhibitors, including first dose hypotension. But are general practitioners right to base their fears on this analysis? All patients in SOLVD had undergone extensive cardiovascular investigation, usually including radionuclide ventriculography and often echocardiography; only 34% of the patients had symptoms; only 43% were taking diuretics; most were men; and they were relatively young. Thus these were not the typical patients with heart failure seen in general practice. Other analyses of these data indicate that the risk of hypotension with the first dose in symptomatic patients is higher than in non-symptomatic patients (see table on the BMJ's website). Therefore it is inappropriate to draw firm conclusions about the safety of starting angiotensin converting enzyme inhibitors in primary care from an analysis of the SOLVD dataset. The NETWORK study indicated that serious first dose hypotension occurred in only 11 of 1566 (0.7%) patients whose treatment was started in hospital.12 Lower rates of first dose hypotension have been reported with perindopril,13 but more data are required to confirm the clinical relevance of this finding.
Lough et al specifically addressed the issue of starting angiotensin converting enzyme inhibitors in primary care in a double blind, randomised placebo controlled study.14 They excluded patients at risk of hypotensive events (by referring them to hospital for initiation of treatment) and observed no hypotensive events among the 178 patients included. These data suggest that, with experience, primary care physicians can identify patients at a low risk of serious first dose hypotension. Nevertheless, care is required. About 150 000 new cases of heart failure occur each year in the UK; a side effect with an incidence of 1% translates into 1500 events a year.
Recently, the IMPROVEMENT of Heart Failure survey, conducted in 14 European countries and including over 11 000 patients, suggested that the uptake of angiotensin converting enzyme inhibitors in general practice is increasing but that treatment is often initiated in hospital,15 reflecting high rates of hospitalisation. β Blockers were grossly underused, and their rapid implementation is now a matter of urgency. Lack of resources and expertise, not fear of side effects, are the great barriers to efficient treatment of heart failure. Proper diagnosis and supervision of treatment for Britain's most common malignant disease should not be beyond the resources of our National Health Service.
A table of hypotensive events in various studies appears in bmj.com