Heart Failure In General Practice Research Articles

Perceived barriers for treatment of chronic heart failure in general practice; are they affecting performance?

BackgroundThe aim of this study is to determine to what extent barriers perceived by general practitioners (GPs) for prescribing angiotensin-converting enzyme inhibitors (ACE-I) in chronic heart failure (CHF) patients are related to underuse and underdosing of these drugs in actual practice.MethodsBarriers were assessed with a semi-structured questionnaire. Prescribing data were extracted from GPs' computerised medical records for a random sample of their CHF patients. Relations between barriers and prescribing behaviour were assessed by means of Spearman rank correlation and multivariate regression modelling.ResultsGPs prescribed ACE-I to 45% of their patients and had previously initiated such treatment in an additional 3.5%, in an average standardised dose of 13.5 mg. They perceived a median of four barriers in prescribing ACE-I or optimising ACE-I dose. Many GPs found it difficult to change treatment initiated by a cardiologist. Furthermore, initiating ACE-I in patients already using a diuretic or stable on their current medication was perceived as barrier. Titrating the ACE-I dose was seen as difficult by more than half of the GPs. No significant relationships could be found between the barriers perceived and actual ACE-I prescribing. Regarding ACE-I dosing, the few GPs who did not agree that the ACE-I should be as high as possible prescribed higher ACE-I doses.ConclusionVariation between GPs in prescribing ACE-I for CHF cannot be explained by differences in the barriers they perceive. Tailor-made interventions targeting only those doctors that perceive a specific barrier will therefore not be an efficient approach to improve quality of care.

Brain natriuretic peptide in heart failure: an improving prognosis?The opinions expressed in this article are not necessarily those of the Editors of the European Heart Journal or of the European Society of Cardiology.

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 [0.50xBNP+5xage+50x(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.

1485 NT Pro-BNP for the Early Diagnosis of Heart Failure in General Practice

1485 NT Pro-BNP for the Early Diagnosis of Heart Failure in General Practice

Deaths from heart failure in general practice: implications for palliative care.

Trial and observational research indicates a high one-year mortality with a significant potential for specialist palliative care for patients with heart failure. A community observational study was undertaken in two general practices, with a total population of 21,000. There were three objectives: to determine the prevalence of symptomatic heart failure, to document mortality in the cohort over six and 12 months, and to establish the population in which a palliative care approach was adopted. A search of the computerized medical records yielded 548 patients with symptomatic heart failure (2.6% of the total study population). Over a six-month period, 31 patients (6% of the cohort) died and over a 12-month period 64 patients (12% of the cohort) died. 'Sudden death' was recorded in the records of 14 patients and death from coexisting malignancy was recorded in seven patients. A palliative care approach in patients not dying suddenly or of malignancy was recorded in 21 cases (33% of the total deaths). The findings do not indicate a high mortality in patients with symptomatic heart failure in general practice. The role of specialist palliative care in many cases would appear to be limited by the difficulty in predicting prognosis. In a significant number of cases, general practitioners appear to be aware of the need for a palliative care approach in patients dying of heart failure.

Plasma brain natriuretic peptide after long-term treatment for heart failure in general practice.

Plasma brain natriuretic peptide (BNP) concentrations are known to have high sensitivity and specificity in the diagnosis of heart failure in newly symptomatic patients. The relationship of plasma BNP to cardiac function in stable patients on long-term established treatment for heart failure is unknown. Plasma BNP was assessed for its ability to predict echocardiographic abnormality in 100 patients receiving long-term treatment in general practice for a provisional diagnosis of heart failure. BNP >35 pmol/l had a sensitivity and specificity of 69% and 67%, respectively, for a left ventricular ejection fraction of <45%. However, 19% of patients had an LVEF of below 45% whilst BNP was below 35 pmol/l. These patients, in whom a diagnosis of heart failure had been made years previously (mean 3.9 years), were all clinically stable on treatment. These findings support the view that BNP can be restored to normal levels in well-compensated patients despite persisting significant systolic dysfunction and suggest that BNP assays may be helpful for monitoring adequacy of therapy. BNP assays will have limited utility in the diagnosis of cardiac impairment once anti-failure therapy is well established and symptoms have been abolished.

Do general practice patients with heart failure understand its nature and seriousness, and want improved information?

This study describes the extent to which patients with heart failure in general practice understand the nature and seriousness of their condition, and want more or better information about it than they currently get. The study involved a random sample of 62 patients receiving care for chronic heart failure in 30 central Auckland, New Zealand, practices. The narrative texts of personal, semi-structured interviews in late 1999 were edited (explicitly and systematically reduced and reassembled) until their interpretation was complete. Approximately 40% of the patients interviewed appeared not to understand the nature and seriousness of their heart failure condition. Two patients had accidentally discovered the diagnosis from inappropriate sources. Eleven patients (18%) expressed wanting improved information about their condition. However, to avoid harm, we did not ask patients about wants for information relating to the seriousness of their heart failure. Through patient education and counselling, providers could help patients to produce an advance written directive of wants for information.

Relations between medical history, clinical findings and plasma N-terminal proatrial natriuretic peptide in patients in primary health care.

recent studies indicate that measurement of natriuretic peptides may be a valuable tool to improve the quality of the diagnosis of heart failure in general practice. the aim of the present study was to examine the relationship between the plasma level of the natriuretic peptide N-terminal proANP and symptoms and signs of heart failure in patients from general practice in the Oslo area. we undertook a survey of 499 patients consecutively enrolled from the practice of 27 practitioners. One hundred and twenty-nine patients were classified as having possible or some degree of heart failure. The plasma concentration of N-terminal proANP increased with severity of heart failure as judged from clinical examination. In multivariate analysis age, history of heart disease, plasma creatinine, use of beta-blockers and digitalis, oedemas and atrial fibrillation were the main determinants of plasma N-terminal proANP. while there was an overall increase in N-terminal proANP values with increasing symptoms and degree of heart failure, no single finding was closely related to N-terminal proANP. Treatment effects and diagnostic errors may both influence the relationship between N-terminal proANP and clinical findings. The current study has demonstrated the feasibility of using N-terminal proANP by general practitioners for the potentially improved diagnosis of heart failure. Further research is required to determine the precise role of this assay in clinical practice.

Angiotensin converting enzyme (ACE) inhibitors in the treatment of heart failure in general practice in north Cumbria.

A great deal of research has demonstrated the benefits of treating patients with chronic heart failure with Angiotensin Converting Enzyme (ACE) inhibitors. There is rather less research on the actual uptake of treatment in general practice, and in particular methods that might improve that uptake. To study the attitudes and practice of medical practitioners in North Cumbria in the treatment of heart failure. Semi-structured interviews with 16 general practitioners and nine hospital physicians in the Carlisle area and an audit of general practice case notes. Two hundred and fifty-eight patients were identified with heart failure. Prevalence was 1.1%. Fifty percent were on an ACE inhibitor, the mean dose of which was less than half the typical research dose. Patients who had an echocardiogram were much more likely to be on an ACE inhibitor. General practitioners were enthusiastic to use ACE inhibitors, but felt that greater access to echocardiography was required. Hospital physicians were happy to improve access within an agreed protocol. Improved uptake of ACE inhibitors could be assisted by the development of a protocol for investigation and treatment. This protocol should be evidence-based and agreed between local GPs, hospital physicians and the Health Authority.

Initiating angiotensin converting enzyme inhibitors in mild to moderate heart failure in general practice: randomised, placebo controlled trial

Less than 50% of patients with heart failure in community practice receive an angiotensin converting enzyme inhibitor and then only usually at the instigation of or when prescribed by a...

A Survey of Heart Failure in General Practice

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.

Management of heart failure in general practice

Management of heart failure in general practice