Difficulties of introducing the National Service Framework for heart failure into general practice in the UK

Prescriptions of recommended heart failure medications can be correlated with patient and physician characteristics

BACKGROUND

Translating the findings from heart failure drug trials into clinical practice has been shown to take time. For the generation of a primary care guideline that takes preferences of general practitioners (GPs) and characteristics of their patients into account, it is necessary to identify the associations between patient and physician characteristics with the prescription of the recommended drugs.

METHODS

We searched for patients with chronic heart failure in the electronic patient records of 14 GPs. In multivariate analyses, we examined the prognostic value of patient and physician characteristics for the prescriptions.

RESULTS

In the 708 identified patients with chronic heart failure, prescription rates for angiotensin converting enzyme inhibitors/angiotensin receptor blockers, beta blockers, diuretics, digitalis and aldosterone antagonists were 50%, 39%, 56%, 35%, and 4%, respectively. On the patient level, age, disease severity, comorbidities and concomitant drug intake were differently related to the prescriptions. On the physician level, age, years of clinical experience and organisation of the practice itself played a differentiating role. conclusion: Our study demonstrates associations between patient and physician characteristics with the prescription of the recommended drugs that should be taken into account to translate guideline recommendations for application in general practice.

Early diagnosis of congestive heart failure: clinical utility of B-type natriuretic peptide testing associated with Doppler echocardiography

OBJECTIVE

B-type natriuretic peptide (BNP) has emerged as an important diagnostic serum marker of congestive heart failure (CHF). The aim of this study was to evaluate whether BNP measurement associated with echocardiography could effectively stratify patients with new symptoms as part of a cost-effective heart failure programme based on cooperation between hospital cardiologists and primary care physicians.

METHODS

Patients were referred to the cardiology clinic by general practitioners in case of clinical suspect of CHF. All patients underwent clinical examination, transthoracic echocardiography and plasma determination of BNP. Systolic dysfunction was defined as a left ventricular ejection fraction < 45%; diastolic dysfunction was defined as a preserved systolic function with signs of diastolic impairment.

RESULTS

Three hundred and fifty-seven subjects were examined (50% males, mean age 73 years). BNP concentration was 469 +/- 505 pg/ml in the 240 patients diagnosed with CHF, compared with 43 +/- 105 pg/ml in the 117 patients without CHF (P = 0.001). CHF patients were grouped into those with diastolic dysfunction (n = 110; BNP 373 +/- 335 pg/ml), systolic dysfunction (n = 108; BNP 550 +/- 602 pg/ml), and both systolic and diastolic dysfunction (n = 22; BNP 919 +/- 604 pg/ml). At receiver operating characteristic analysis, the optimal BNP cut-off level for diagnosing CHF was 80 pg/ml (sensitivity 84%, specificity 91%). According to cost analysis, this cut-off level might provide a cost saving of 31% without affecting diagnostic accuracy.

CONCLUSIONS

In patients referred by general practitioners for suspected CHF, plasma BNP levels might help to stratify subjects into different groups of cardiac dysfunction.

Diagnosis of heart failure in primary care

Heart failure is becoming an increasing concern to healthcare worldwide. It is the only cardiovascular disorder that continues to increase in both prevalence and incidence, and as the population continues to age, it is expected that the prevalence of this disease will continue to rise. Guidelines on diagnosis and treatment of heart failure are to be met. Most patients with heart failure will present themselves in general practice. Therefore, the community management of heart failure has become increasingly important and the role of General Practitioners even more crucial. Improving the reliability of diagnosis in primary care is essential since determining the aetiology and stage of heart failure leads to different management choices to improve symptoms, quality of life and disease prognosis. Furthermore, early diagnosis is needed, when there may be no symptoms, since treatment can delay or reverse disease progression. Diagnostic methods may therefore need to encompass screening strategies, as well as symptomatic case identification, in the future. General Practitioners must make correct decisions regarding appropriate further investigation, treatment and referral. A correct diagnosis is the cornerstone leading to effective management. The aim of this paper is to review the role of symptoms and signs and diagnostic tests, such as, chest X-ray, ECG, natriuretic peptides and echocardiography, for diagnosing heart failure in the primary care setting. Improving diagnostic skills remains a continuous challenge for clinicians. Simple and reliable diagnostic procedures are crucial to comply with Guidelines and reduce healthcare utilisation and costs.

Management of chronic heart failure: perceived needs of general practitioners in light of the new general medical services contract

BACKGROUND

Despite the existence of several chronic heart failure (CHF) guidelines the treatment of patients with CHF is suboptimal. The new general medical services (GMS) contract in primary care has only three specific performance indicators for patients with left ventricular dysfunction. The aim of this current questionnaire survey was to assess the views of general practitioners (GPs) on CHF treatments and services in light of the new GMS contract.

METHODS AND RESULTS

All local GPs (717) were sent a questionnaire. Fifty three per cent were returned. Forty five per cent of GPs had access to a community CHF nurse. Having read a national guideline (SIGN) and having the support of a CHF nurse did not seem to affect the knowledge of GPs in terms of perceived benefits of drug treatments. GPs with access to a specialist CHF nurse service attached more importance to it than those with no specialist nurse (p = 0.003).

CONCLUSIONS

Most GPs were aware of the existence of a national guideline but many had not read it. There was little or no difference in the knowledge level for various evidence based treatments between GPs who had or had not read the guideline suggesting that reading guidelines may not be a key factor in determining knowledge. Support for a specialist CHF nurse was higher among GPs who already had this service, suggesting that this service is valued. The new GMS contract may improve identification and diagnosis of patients with CHF but there is a danger that it may fall short of ensuring optimal treatment for patients with CHF.

The NT-proBNP assay identifies very elderly nursing home residents suffering from pre-clinical heart failure

BACKGROUND

Little is known about the prevalence of heart failure among very old people, although hospitalisation rates for chronic heart failure are very high. Recently, brain natriuretic peptides have emerged as important diagnostic and prognostic serum markers for congestive heart failure.

AIMS

The main purpose of our study was to determine whether there is a cut-off for NT-proBNP for detecting the echocardiographic features of left ventricular systolic and/or diastolic dysfunction and clinical heart failure among old people living in nursing homes. Secondarily, we investigated the medium-term prognostic power of the neurohormone levels.

METHODS

We screened 101 old people (80% females, aged 84+/-9 years) from two nursing homes. We prospectively evaluated whether we could effectively stratify patients using a combination of (1) restrictive clinical criteria, (2) NT-proBNP measurements (Elecsys System, Roche Diagnostics) and (3) echocardiography for all patients.

RESULTS

Forty-two percent of the subjects had left ventricular dysfunction: 11% systolic, 23% diastolic and 8% both systolic and diastolic. The mean NT-proBNP concentration was 2806+/-7028 pg/ml in the 42 patients with left ventricular systolic and/or diastolic dysfunction, compared with 365+/-456 pg/ml in the 59 patients with normal left ventricular function (p<0.01, Z=-4.8 Mann-Whitney U test). The neurohormone proved to be a good predictor of events within 6 months [area under the receiver-operated curve (ROC)=0.79].

CONCLUSIONS

Blood NT-proBNP concentrations can play an important role in stratifying old people into left ventricular dysfunction risk groups. The neurohormone is an independent marker for death or admission for heart failure in the medium term.

Using BNP to develop a risk score for heart failure in primary care

AIMS

Chronic heart failure is a common condition with high mortality. Accurate diagnosis in primary care is difficult. Elevated B-type natriuretic peptide (BNP) is associated with left ventricular systolic dysfunction and increased mortality. Prognostic scoring systems using BNP may help to stratify risk in primary care patients. The aim of this research was to establish the independent variables which predict mortality in a primary care population-prescribed loop diuretics and to generate and validate a scoring system for heart failure in general practice.

METHODS AND RESULTS

Five hundred and thirty-two patients were followed up for a mean of 6.4 years after attending a research clinic for clinical assessment, electrocardiogram (ECG), echocardiography, and BNP. Multivariate analysis was used to establish independent prognostic variables and to generate a prognostic scoring system. The score generated was [0.50 x BNP+5 x age+50 x (CVA+sex+diabetes+ECG)]. The cut-off scores for risk groups were; 25th percentile, 411; 50th percentile, 475; 75th percentile, 524; Harrell's c=0.75.

CONCLUSION

Developing prognostic scoring systems provides a means of risk stratifying patients without relying on a single cut-off diagnostic value for BNP. Further validation of such scoring systems may improve future management of community heart failure patients.

The diagnosis and management of chronic heart failure in the older patient

Chronic heart failure is a common problem in old age. Dyspnoea and fatigue are the most common symptoms and should alert the clinician to the likely diagnosis. When there is a clinical suspicion of heart failure, further assessment is required to confirm the aetiology. In older patients, heart failure with normal systolic function is frequently encountered. However, patients with left ventricular systolic dysfunction usually have a poorer prognosis, and most treatments have been evaluated in these patients. Useful investigations include the 12-lead electrocardiogram, chest radiology and echocardiography. A blood test for B-type natriuretic peptide is being increasingly used as a 'rule out' test for heart failure. There are several treatment options. Initially, patients should be treated with a diuretic and ACE inhibitor, provided there are no contraindications. beta-Blocker therapy is also first-line therapy once a patients' haemodynamic status has been stabilized. Additional treatments include spironolactone, angiotensin antagonists and digoxin. Patient factors and tolerability may limit the number of treatment options. Treatment regimes are most effective when delivered using a multidisciplinary approach.

The diagnosis of heart failure in general practice: implications for the UK National Service Framework

BACKGROUND

The UK National Service Framework recommends patients with suspected heart failure undergo echocardiography. Selection of patients for this investigation in primary care is difficult. It is not clear which clinical features best identify patients with left ventricular systolic dysfunction.

AIM

Using echocardiography, to establish the accuracy of primary care diagnosis of left ventricular systolic dysfunction. To investigate the sensitivity, specificity and predictive values of clinical features in the diagnosis of left ventricular systolic dysfunction.

STUDY

A cross-sectional study of 621 patients from a population prescribed loop diuretics in 7 general practices.

METHOD

Clinical diagnoses were extracted from general practice records. Symptoms, clinical signs, ECG features, brain natriuretic peptide levels and echocardiographic findings were studied in a research clinic.

RESULTS

Left ventricular systolic dysfunction (ejection fraction <40%) was present in 50% of 621 patients prescribed loop diuretics in primary care. General practice diagnoses showed high false positive rates. Individual or combinations of clinical features did not accurately predict left ventricular systolic dysfunction.

CONCLUSION

These results suggest the clinical diagnosis of left ventricular systolic dysfunction is inaccurate in this population. General practitioners should have a low threshold for referring patients prescribed loop diuretics for echocardiography. Increased open access echocardiography facilities will be needed.