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Rapid response to:


Randomised controlled trial of specialist nurse intervention in heart failure

BMJ 2001; 323 doi: (Published 29 September 2001) Cite this as: BMJ 2001;323:715

Rapid Response:

Specialist nurse intervention in heart failure


The important article by Blue et al (1) underlines the clinical value
of a cohesive strategy for the management of heart failure patients. The
reduction in events, notably rehospitalisations, is supported by
observations from other centres, including our own (2). However, it is our
opinion that to be absolutely sure that this intervention explains the
difference in rehospitalisation rates, all other important variables must
be standardised within the two groups. It appears from table 2 that
patients from the intervention group were discharged from hospital on a
higher dose of angiotensin converting enzyme inhibitor than the usual care
group. It has been well demonstrated that high-dose ACEI therapy is
associated with a lower risk of hospitalisation following discharge than
low-dose treatment (3).

Therefore, while we agree with the authors conclusion that nurse-led
intervention reduces morbidity in heart failure patients, we feel the data
provided leaves unanswered the impact of final dose of angiotensin
converting enzyme inhibitor at discharge.

Finally, this study included only patients with heart failure and
reduced systolic function, in spite of the fact that as many as 30-40% of
patients presenting with clinical manifestations of heart failure have
normal systolic function (4). 51% of eligible patients were excluded for
this reason. However, recent data suggest the morbidity of the two types
of heart failure is similar (5). Intervention that primarily influences
morbidity, as described in this study, may be even more important in
patients with preserved systolic function heart failure, given that our
knowledge of which therapies influence prognosis and morbidity in this
condition is lacking,

Yours sincerely,

Dr. Enda Ryan M.R.C.P.I.,

Cardiology Registrar,

St. Vincent’s University Hospital,
Dublin 4, Ireland.

Dr. K. McDonald M.D., F.R.C.P.I.,

Consultant Cardiologist,

St. Vincent’s University Hospital,
Dublin 4, Ireland.


1) “Randomised controlled trial of specialist nurse intervention in heart
L Blue et al. BMJ Vol 323, 29 Sept 2001, p715-718

2) “Elimination of early rehospitalization in a randomised controlled
trial of multidisciplinary care in a high-risk, elderly heart failure
population: the potential contribution of specialist care, clinical
stability and optimal angiotensin converting enzyme inhibitor dose at
Ken McDonald et al. European Journal of Heart Failure Vol 3 (2)
2001 p209-215.

3) “ Comparative effects of low and high doses of the angiotensin
converting enzyme inhibitor, lisinopril, on morbidity and mortality in
chronic heart failure. ATLAS Study group.”
M Packer et al Circulation 1999 Dec 7; 100(23): 2312-8.

4) “Heart failure with normal systolic function”.
Kessler KM Arch Intern Med 1988; 148: 2109-2111.

5) “Congestive heart failure with preserved systolic function in a state-
wide sample of community hospitals”. Dauterman KW et al.
Journal of Cardiac Failure Vol 7 No. 3 2001.

Competing interests: No competing interests

12 November 2001
Enda Ryan
Cardiology Registrar.
St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland.