A Survey of Heart Failure in General Practice

Abstract

Objectives: To investigate the prevalence, clinical features and management of patients with heart failure in the primary care setting.Methods: Cross-sectional survey of patients using treatment prescriptions, computerised disease records and clinical records. Three group general practices in West Birmingham, England (serving a patient popultion of 25819) where 7555 subjects (29.3%) were aged over 40 years.Results: We found 188 patients aged over 40 years who were being treated for heart failure (2.4%; 85 males; mean age 72 years, s.d. 9): 2.2% of patients were aged 40-50 years, 6.5% aged 51-60 years, 23.4% aged 61-70, and 68.2% aged >70 years. Female patients were significantly older than male patients (mean age 75 vs. males 70 years, t-test p<0.01). Of the patients studied, 90 (47.9%) had heart failure diagnosed on presentation to the general practitioner, 76 (40.4%) to hospital practice (as acute presentations or non-specialist outpatient clinic) and 5 (2.7%) only on attending a specialist cardiology outpatient clinic. The commonest associated factors were myocardial infarction in 100 patients (53.2%), hypertension in 67 (35.6%), diabetes in 45 (23.4%), valvular heart disease in 13 (6.9%) and cardiomyopathy in 29 (15.4%). Atrial fibrillation was present in 55 patients (29.2%), and of these 34 had had a previous stroke or thromboembolism.Echocardiography was performed in only 67 patients (35.6%) and a chest x-ray in 121 (64.4%). Drugs commonly prescribed included diuretics in 181 (96.3%), nitrates in 115 (61.2%), digoxin in 65 (34.6%), calcium antagonists in 43 (22.9%) and angiotensin converting enzyme (ACE) inhibitors in 110 (58.5%). Aspirin was used in 82 (43.6%), predominantly for previous myocardial infarction (79/82). After diagnosis of heart failure, 44% of hospital attendances (in and outpatients) occurred <3 months after diagnosis, 32.3% between 3-6 months, and 23.3% occurring >6 months; corresponding general practice consultations were 43.7%, 22.9% and 33.9% respectively.Conclusions: Heart failure is a common problem in the primary care setting, and is commonly associated with ischaemic heart disease, hypertension and diabetes. There was a suboptimal application of standard investigations, including echocardiography, and the use of established therapy such as ACE inhibitors. After the initial diagnosis, most hospital and general practice attendances occurred in the first three months. This audit may have implications for service and resource provision for the community management of heart failure.