Abstract
BackgroundDiagnosing heart failure and left ventricular systolic dysfunction is difficult on clinical grounds alone. We sought to determine the accuracy of a heart failure register in a single primary care practice, and to examine the usefulness of b-type (or brain) natriuretic peptide (BNP) assay for this purpose.MethodsA register validation audit in a single general practice in the UK was carried out. Of 217 patients on the heart failure register, 56 of 61 patients who had not been previously investigated underwent 12-lead electrocardiography and echocardiography within the practice site. Plasma was obtained for BNP assay from 45 subjects, and its performance in identifying echocardiographic abnormalities consistent with heart failure was assessed by analysing area under receiver operator characteristic (ROC) curves.Results30/217 were found to have no evidence to suggest heart failure on notes review and were probably incorrectly coded. 70/112 who were previously investigated were confirmed to have heart failure. Of those not previously investigated, 24/56 (42.9%) who attended for the study had echocardiographic left ventricular systolic dysfunction. A further 8 (14.3%) had normal systolic function, but had left ventricular hypertrophy or significant valve disease. Overall, echocardiographic features consistent with heart failure were found in only 102/203 (50.2%). BNP was poor at discriminating those with and without systolic dysfunction (area under ROC curve 0.612), and those with and without any significant echocardiographic abnormality (area under ROC curve 0.723).ConclusionIn this practice, half of the registered patients did not have significant cardiac dysfunction. On-site echocardiography identifies patients who can be removed from the heart failure register. The use of BNP assay to determine which patients require echocardiography is not supported by these data.
Highlights
Diagnosing heart failure and left ventricular systolic dysfunction is difficult on clinical grounds alone
It is well recognised that diagnosing heart failure and LVSD upon clinical grounds alone is beset with difficulties due to the limited specificity and sensitivity of typical symptoms
Patients who had not previously had any such investigation were invited to attend for electrocardiography, venepuncture, and echocardiography, all performed in one visit to the general practice
Summary
Diagnosing heart failure and left ventricular systolic dysfunction is difficult on clinical grounds alone. Heart failure is an increasingly prevalent condition, associated with markedly reduced survival and quality of life despite recent advances in management [1]. The prevalence of heart failure in the community is around 2%, and a similar proportion has left ventricular systolic dysfunction (LVSD, an important precursor of heart failure) [2]. It is well recognised that diagnosing heart failure and LVSD upon clinical grounds alone is beset with difficulties due to the limited specificity and sensitivity of typical symptoms. Modern diagnostic criteria for heart failure stipulate the need to identify objective evidence of cardiac dysfunction [5]. Planned service contractual changes should further encourage general practitioners to request such investigations
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