Open access echocardiography in management of heart failure in the community

Long term survival of patients with raised pulmonary arterial systolic pressure utilizing echocardiography-a five-year prospective study

Background

Pulmonary arterial systolic pressure (PASP) can be estimated with transthoracic echocardiography. However, the significance of raised PASP on routine echocardiography is uncertain. In this study, we evaluated the mortality and hospitalization rates of subjects with raised PASP in a cohort of patients referred directly by their general practitioners for routine outpatient (open access) echocardiography for further analysis of suspected heart failure.

Results

A total of 485 subjects were referred for open access echocardiography at our hospital in 2002. A cohort of 209/485 (43%) consecutive subjects with measurable tricuspid regurgitation were followed for a minimum of five years investigating hospitalization rates and survival. Some 62 of 209 (30%) subjects had pulmonary hypertension (PH). Subjects with PH were significantly more likely to have four or more hospital admissions (22% vs. 8%; P < 0.01) and > 30 days of cumulative hospital stay over five years (29% vs. 13%; P < 0.01). PH was significantly associated with mortality (P = 0.003), while moderate to severe PH was an independent predictor of mortality (hazard ratio: 4.31; 95% confidence interval (95% CI): 1.51–12.30). Records from the Office of National Statistics revealed that subjects with PH were more likely to have chronic lung diseases recorded as immediate or contributory causes of death (50% vs. 14%; P < 0.05).

Conclusions

PASP ≥ 36 mmHg on routine echocardiography is associated with recurrent hospital admissions, prolonged hospitalizations and increased cause of mortality. Therefore, the diagnosis of PH on echocardiography deserves further clinical evaluation, with future studies designed at defining a suitable diagnostic strategy.

The Dutch experience of open access echocardiography

Cardiac disease is not easy to recognise in general practice. An echocardiogram is an excellent way to provide information about left ventricular mass and diastolic (dys)function and the presence of valvular heart disease. To improve diagnostic care of cardiac patients, an open access echocardiography service was established in the referral area of our hospital, where general practitioners were able to ask for an echocardiogram without referring the patient to the cardiologist. Between December 2002 and October 2006 echocardiograms were requested for 471 patients. Thirteen percent of the patients referred for dyspnoea and 3% of patients with a cardiac murmur had a left ventricular ejection fraction <40%. In 28% of patients no cardiac abnormality could be found. If we looked at the prevalence of hypertension in the referred patients, this was very high with a prevalence of up to 60% in the older age groups. If we included hypertension in the analysis, only 16% of patients had no structural cardiac or vascular abnormality. The study shows that the advantage of open access echocardiography in the Netherlands is that the general practitioner is able to make a better diagnosis and unnecessary referrals of patients with suspected cardiac disease can be avoided. (Neth Heart J 2007;15:342-7.).

Efficacy of ACE inhibitors in chronic heart failure with preserved ejection fraction--a meta analysis of 7 prospective clinical studies

BACKGROUND

The effect of ACE inhibitors on the prognosis of chronic heart failure patients with preserved left ventricular ejection fraction remains controversial.

AIMS

To assess the impact of ACE inhibitors on the prognosis of chronic heart failure patients with preserved left ventricular ejection fraction.

METHODS AND RESULTS

Seven prospective studies evaluating the effect of ACE inhibitors compared to placebo or other classes of drugs, such as monotherapy or first-line therapy, on the prognosis of chronic heart failure patients with preserved left ventricular ejection fraction were included. A total of 2554 patients (mean age: 75.1 years, female: 58%) were recruited with an average follow up of 20.9 months. The primary etiology of heart failure with preserved ejection fraction was ischemic heart disease (33.7%), hypertension (69.1%) and diabetes mellitus (25.8%). Our results demonstrated that ACE inhibitors significantly reduced all-cause mortality (odds ratio, OR = 0.52; 95% Confidence Interval (CI), 0.41 to 0.64; P<0.01). Furthermore, ACE inhibitors were able to reduce heart failure related rehospitalization or treatment over 20.9 months (p<0.05) in a subgroup of patients aged over 75 years. However, death due to worsening of heart failure, heart failure related rehospitalization and any-cause readmission were not affected (OR = 0.88; 95% CI: 0.66 to 1.17; P = 0.37 for death due to worsening of heart failure; OR = 0.81; 95% CI: 0.63 to 1.05; P = 0.11 for heart failure related rehospitalization and OR = 0.88; 95% CI: 0.68 to 1.14; P = 0.33 for any-cause readmission, respectively).

CONCLUSIONS

In patients with chronic heart failure with preserved ejection fraction, ACE inhibitors reduced all-cause mortality without affecting mortality due to heart failure and any-cause rehospitalization.

Evaluation of an open access echocardiography service in the Netherlands: a mixed methods study of indications, outcomes, patient management and trends

BACKGROUND

In our region (Eastern South Limburg, The Netherlands) an open access echocardiography service started in 2002. It was the first service of this kind in The Netherlands. Our study aims were: (1) to evaluate demand for the service, participation, indications, echocardiography outcomes, and management by the general practitioner (GP); (2) to analyse changes in indications and outcomes over the years.

METHODS

(1) Data from GP request forms, echocardiography reports and a retrospective GP questionnaire on management (response rate 83%) of 625 consecutive patients (Dec. 2002-March 2007) were analysed cross-sectionally. (2) For the analysis of changes over the years, data from GP request forms and echocardiography reports of the first and last 250 patients that visited the service between Dec. 2002 and Feb. 2008 (n = 1001) were compared.

RESULTS

The echocardiography service was used by 81% of the regional GPs. On average, a GP referred one patient per year to the service. Intended indications for the service were dyspnoea (32%), cardiac murmur (59%), and peripheral oedema (17%). Of the other indications (22%), one-third was for evaluation of suspected left ventricular hypertrophy (LVH). Expected outcomes were left ventricular dysfunction (LVD) (43%, predominantly diastolic) and valve disease (25%). We also found a high proportion of LVH (50%). Only 24% of all echocardiograms showed no relevant disease. The GP followed the cardiologist's advice to refer the patient for further evaluation in 71%. In recent patients, more echocardiography requests were done for 'cardiac murmur' and 'other' indications, but less for 'dyspnoea'. The proportions of patients with LVD, LVH and valve disease decreased and the proportion of patients with no relevant disease increased. The number of advices by the cardiologists increased.

CONCLUSION

Overall, GPs used the open access echocardiography service efficiently (i.e. with a high chance of finding relevant pathology), but efficiency decreased slightly over the years. To meet the needs of the GPs, indications might be widened with 'suspicion LVH'. Further specification of the indications for open access echocardiography--by defining a stepwise diagnostic approach including ECG and (NT-pro)BNP--might improve the service.

Novel strategies for the detection of systolic and diastolic heart failure

The incidence and prevalence of dyspnea increases with age. Frequently, for the general practitioner with his limited diagnostic facilities, it is impossible to separate dyspnea from cardiac causes and non-cardiac causes. Without cardiac imaging it is also impossible to separate systolic dysfunction from diastolic dysfunction. After a thorough physical examination, initial screening of systolic and diastolic heart failure can be done by measurement of plasma NT-pro BNP or plasma BNP. Additionally a Chest X-Ray or ECG can be performed. To improve diagnostic performance an open access echocardiographic service can be initiated. Recent studies showed, that open access echocardiography can easily detect systolic and diastolic dysfunction in the community and can separate cardiac from non-cardiac dyspnea.

Diagnostic characteristics of combining phonocardiographic third heart sound and systolic time intervals for the prediction of left ventricular dysfunction

BACKGROUND

The third heart sound (S3) and systolic time intervals (STIs) are validated clinical indicators of left ventricular (LV) dysfunction. We investigated the test characteristics of a combined score summarizing S3 and STI results for predicting LV dysfunction.

METHODS AND RESULTS

A total of 81 adults underwent computerized phonelectrocardiography for S3 and STI (Audicor, Inovise Medical Inc), cardiac catheterization for LV end-diastolic pressure (LVEDP), echocardiography for LV ejection fraction (LVEF), and B-type natriuretic peptide (BNP) testing. LV dysfunction was defined as both an LVEDP >15 mm Hg and LVEF <50%. The STI measured was the electromechanical activation time (EMAT) divided by LV systolic time (LVST). Z-scores for the S3 confidence score and EMAT/LVST were summed to generate the LV dysfunction index. The LV dysfunction index had a correlation coefficient of 0.38 for LVEDP (P = .0003), -0.53 for LVEF (P < .0001), and 0.35 for BNP (P = .0008). This index had a receiver operative curve c-statistic of 0.89 for diagnosis of LV dysfunction; a cutoff >1.87 yielded 72% sensitivity, 92% specificity, 9.0 positive likelihood ratio, and 88% accuracy.

CONCLUSIONS

In this preliminary study, the LV dysfunction index combined S3 and STI data from noninvasive electrophonocardiography, and yielded superior test characteristics compared to the individual tests for the diagnosis of LV dysfunction.

Cost‐Effective Strategies to Screen for Left Ventricular Systolic Dysfunction in the Community—A Concept

Early detection of heart failure caused by left ventricular systolic dysfunction (LVSD) is important, since early treatment has been shown to retard the progression of heart failure. While traditional echocardiography remains the standard for the detection of LVSD, electrocardiography and serum brain natriuretic peptide have also been shown to predict LVSD. Recently, hand-held echocardiography systems have been shown to have high predictive accuracy for assessment of LVSD. With the availability of the above bedside and relatively less-costly techniques, compared with traditional echocardiography, the major question now is what is the most cost-effective strategy for screening subjects for LVSD. To date, no studies have systematically addressed this issue, but preliminary data are becoming available. This review article discusses the pros and cons of various investigative strategies and likely cost-effectiveness of each strategy to screen for LVSD.

Impact of specialist care in patients with newly diagnosed heart failure: A randomised controlled study

AIM

To assess the feasibility and impact of specialist care in patients with newly diagnosed heart failure in primary and secondary care.

METHODS

Patients with suspected heart failure referred for open access echocardiography to a hospital-based echocardiography service were assessed from June 2002 through to June 2003. Patients with confirmed left ventricular systolic dysfunction (LVSD) were randomised to specialist care (cardiology registrar and heart failure nurses) or referred back to their general practitioner (GP). Randomisation was stratified for age and sex and both groups were comparable. All patients were followed up for a minimum of 3 months post randomisation with a mean follow-up time of 10+/-3 months. Specialist care was provided both in the community and in hospital. The primary endpoint was prescription of optimum heart failure medication and secondary endpoint was a composite endpoint of all cause mortality and/or hospital admission.

RESULTS

386 patients were screened; mean age -72+/-10 years. 113 (29%) had confirmed LVSD on echocardiography and were randomised to specialist or primary care. The prescription of ACE-inhibitors (85% vs. 64%) and beta blockers (50% vs. 2%) was higher in patients randomised to specialist care. No significant differences were noted in mortality or hospitalisation.

CONCLUSION

Specialist heart failure care results in higher rates of optimal prescribing, in primary and secondary care.

Treating the right patient at the right time: Access to echocardiography in Canada

The Canadian Cardiovascular Society is the national professional society for cardiovascular specialists and researchers in Canada. In the spring of 2004, the Canadian Cardiovascular Society Council formed the Access to Care Working Group ('Working Group') to use the best science and information available to establish reasonable triage categories and safe wait times for access to common cardiovascular procedures. The Working Group decided to publish a series of commentaries to initiate a structured national discussion on this important issue, and the present commentary proposes recommended wait times for access to echocardiography. 'Emergent' echocardiograms should be performed within 24 h, 'urgent' within seven days and 'scheduled' (elective) within 30 days. A framework for a solution-oriented approach to improve access is presented.

Open access echocardiography is feasible in the Netherlands

OBJECTIVES

In an urban region in the Netherlands, general practitioners (GPs) were offered an open access echocardiographic service. We report the outcomes of the first two years of this project.

METHODS

GPs were given a course on the indications and restrictions for diagnostic referral as well as the interpretation of echocardiographic results. Indications were restricted to `dyspnoea', `cardiac murmur' and `peripheral oedema'. A uniform request form was developed, using ticking boxes for quick completion. The echocardiogram was performed within one week after the request. Results were interpreted by the cardiologist according to the criteria of the Dutch, European and American Societies of Echocardiography.

RESULTS

Sixty GPs from 43 general practices participated, covering a practice population of 130,000 persons. During a period of 24 months, 198 patients were referred. Only 1.5% of the workload of the echocardiography department was due to requests from GPs. The GPs kept well to the agreements on indications for echocardiography (91% approved reasons). An abnormal echocardiographic outcome was found in 53% of all patients. For `cardiac murmur' this was 52%, for `dyspnoea' 63%, and for `peripheral oedema' 58%. Left ventricular dysfunction was present in 49 patients (25%); diastolic dysfunction was present in most of them (39 patients, 19%). Systolic dysfunction (LVEF < 40%) was found in 19 patients (10%). Twenty patients (10%) appeared to have relevant aortic or mitral valve disease.

CONCLUSION

GPs did not overuse the open access echocardiographic service; they possibly used it conservatively. To prevent underdiagnosis of left ventricular dysfunction, diagnostic strategies in which electrocardiogram, NT-pro-BNP and echocardiography are combined, should be developed.

Treating the right patient at the right time: access to specialist consultation and non-invasive testing

The Council of the Canadian Cardiovascular Society commissioned working groups to examine issues of access to, and wait times for, various aspects of cardiovascular care. The present article summarizes the deliberations on targets for medically acceptable wait times for access to cardiovascular specialist evaluation and on the performance of noninvasive testing needed to complete this evaluation. Three categories of referral indications were identified: those requiring hospitalization due to substantial ongoing risk of mortality and morbidity; those requiring an expedited early review in an ambulatory setting; and, finally, a larger category in which delays of two to six weeks can be justified. The proposed wait time targets will provide guidance on the timeliness of care to busy clinicians charged with the care of patients with cardiovascular disease, help policy makers appreciate the clinical challenges in providing access to high quality care, and highlight the critical need for a thoughtful review of cardiology human resource requirements. Wait time implementation suggestions are also included, such as the innovative use of disease management and special need clinics. The times proposed assume that available clinical practice guidelines are followed for clinical coronary syndrome management and for treatment of associated conditions such as hypertension, diabetes, renal disease, smoking cessation and lipid disorders. Although media attention tends to focus on wait times for higher profile surgical procedures and high technology imaging, it is likely that patients face the greatest wait-related risk at the earlier phases of care, before the disease has been adequately characterized.

Rapid brain natriuretic peptide test and Doppler echocardiography for early diagnosis of mild heart failure

BACKGROUND

The early identification of patients at risk for the development of clinical heart failure (HF) is a new challenge in an effort to improve outcomes.

METHODS

We prospectively evaluated whether the combination of brain natriuretic peptide (BNP) measurements (Triage BNP test, Biosite Diagnostics) and echocardiography would effectively stratify patients with new symptoms in a cost-effective HF program aimed at early diagnosis of mild HF. A total of 252 patients were referred by 100 general practitioners.

RESULTS

Among the study population, the median BNP value was 78 ng/L (range, 5-1491 ng/L). BNP concentrations were lower among patients without heart disease [median 15 ng/L (range, 5-167 ng/L); n = 96] than among patients with confirmed HF [median, 165 ng/L (22-1491 ng/L); n = 157; Mann-Whitney U-test, 12.3; P <0.001]. Patients were grouped into diastolic dysfunction [BNP, 195 (223) ng/L], systolic dysfunction [BNP, 290 (394) ng/L], and both systolic and diastolic dysfunction [BNP, 776 (506) ng/L]. In this model, a cutoff value of 50 ng/L BNP increases the diagnostic accuracy in predicting mild HF, avoiding 41 echocardiograms per 100 patients studied, with a net saving of 14% of total costs.

CONCLUSIONS

Blood BNP concentrations, in a cost effective targeted screening, can play an important role in diagnosing mild HF and stratifying patients into risk groups of cardiac dysfunction.

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.

Using the emergency department clinical decision unit for acute decompensated heart failure

Acute decompensated heart failure (ADHF) is a complex disease of epidemic proportions. In the United States, it accounts for more than 1 million hospitalizations annually,and heart failure represents the single greatest cost to the Centers for Medicaid and Medicare Studies. Half of the annual costs are estimated to be the result of hospitalization. Compared with other pathology, heart failure has a very high hospitalization rate, with 80% of emergency department ADHF patients being admitted. This high rate has resulted from the lack of successful management predictors available to the emergency physician and the lack of any disposition option other than hospitalization for the ADHF patient. The emergency department observation unit offers an alternative to hospitalization for patients with ADHF. Validated protocols have demonstrated that in ADHF, intensive short-term therapeutic, diagnostic, and educational protocols result in a marked improvement in hospitalization rates, while at the same time decreasing costs. New risk stratification data can aid in the identification of the appropriate candidate. The observation unit now represents a nonhospitalization disposition option for patients presenting to the emergency department with ADHF.viii CO

Uncovering a hidden epidemic: a study of the current burden of heart failure in Australia

BACKGROUND

Australia, like other countries, is experiencing an epidemic of heart failure (HF). However, given the lack of national and population-based datasets collating detailed cardiovascular-specific morbidity and mortality outcomes, quantifying the specific burden imposed by HF has been difficult.

METHODS

Australian Bureau of Statistics (ABS data) for the year 2000 were used in combination with contemporary, well-validated population-based epidemiologic data to estimate the number of individuals with symptomatic and asymptomatic HF related to both preserved (diastolic dysfunction) and impaired left ventricular systolic (dys)function (LVSD) and rates of HF-related hospitalisation.

RESULTS

In 2000, we estimate that around 325,000 Australians (58% male) had symptomatic HF associated with both LVSD and diastolic dysfunction and an additional 214,000 with asymptomatic LVSD. 140,000 (26%) live in rural and remote regions, distal to specialist health care services. There was an estimated 22,000 incidents of admissions for congestive heart failure and approximately 100,000 admissions associated with this syndrome overall.

CONCLUSION

Australia is in the midst of a HF epidemic that continues to grow. Overall, it probably contributes to over 1.4 million days of hospitalization at a cost of more than 1 billion dollars. A national response to further quantify and address this enormous health problem is required.

Easy Access Echocardiography for the General Practicioner: Results from the Parkstad Area in The Netherlands

Heart failure has a low incidence in general practice but is not easy to recognize in this setting. Frequently a normal electrocardiogram and a normal level of brain natriuretic peptide can exclude heart failure as a cause for dyspnea. Unfortunately the positive predictive value of both techniques is low. Imaging with echocardiography can then give the clue to the correct diagnosis. Also correct diagnosis of cardiac murmurs is not easy in general practice. Therefore an open access echocardiographic service was established in the south of the Netherlands. According to the existing services in the United Kingdom general practitioners in this area were able to ask for an echocardiogram without referring the patient to the cardiologist. During a period of 19 months 131 patients were referred to the Centre of Medical Diagnostics for an echocardiogram. In 12% of the patients referred for dyspnea a left ventricular ejection fraction lower than 40% was found. Fourty nine percent of the patients had diastolic dysfunction. In 33% heart failure could be excluded. In 62% of the patients referred for a cardiac murmur cardiac pathology could be found. In 38% of the patients the cardiac murmur could be established as a functional murmur. The service was found to improve practice by most of the general practitioners.

Agreement between community echocardiography and hospital echocardiography in patients suspected of having left ventricular systolic dysfunction

BACKGROUND

Smaller echocardiography machines, when used in hospitals, are accurate for detecting left ventricular dysfunction and valvular disease. This paper assessed the detection of left ventricular dysfunction and of valvular disease in the community setting by a smaller machine.

AIMS

To measure the agreement in patients with suspected heart failure between community echocardiography and traditional echocardiography in the hospital in detecting left ventricular dysfunction and significant valve disease.

METHODS

Suspected heart failure patients were referred to one of the authors (SJ) for community echocardiography using a Siemens Cypress machine. The patients had a second echocardiogram in the hospital by another sonographer who was blinded to the results of the first echocardiogram. The reports of the two sonographers were assessed for agreement using kappa statistics.

RESULTS

458 patients had a community echocardiogram and 136 agreed to a second echocardiogram in the hospital. There was excellent agreement, kappa = 0.87 (0.06 SE), for the detection of left ventricular dysfunction between community echocardiography and the hospital machine. The detection of significant valvular disease was good, kappa = 0.75 (0.06) between the community echocardiogram and hospital machines.

CONCLUSIONS

In suspected heart failure patients, community echocardiography gives comparable results to traditional hospital echocardiography for left ventricular dysfunction detection and for significant valvular disease detection.

Open access echocardiography has diagnostic yield similar to outpatient echocardiography and is highly rated by general practitioners and patients

BACKGROUND

Open access echocardiography is widely available to General Practitioners (GP). There is little data comparing the proportion of echocardiographic studies which are abnormal in open access series with that in hospital outpatient practice. This study compares the diagnostic yield from echocardiograms performed for similar indications by open access and hospital out patient requested groups and assesses the attitudes of GPs and patients to open access echocardiography.

METHODS

The reports of 151 consecutive patients who had open access echocardiograms were analysed using predefined criteria for an abnormal study. The reports of 100 consecutive patients who had a new outpatient requested echocardiograms for similar indications were used as the control group. The attitudes of GPs and patients to the open access service were also assessed.

RESULTS

Fifty seven percent of patients in the open access group and 51% in the hospital requested group had abnormal studies (p>0.05). 92% of GPs who responded to the questionnaire thought the report was easy to understand while 69% thought it led to a change in patient management. 74% said a clinic referral would have been made without this service and 79% preferred a management strategy to be included in the report. 90% of patients had been informed of the result by their GP.

CONCLUSIONS

Open access echocardiography has a diagnostic yield similar to echocardiograms requested on new hospital outpatients in a district general hospital setting. GPs and patients report high levels of satisfaction with this service.

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.

The value of the electrocardiogram and chest X-ray for confirming or refuting a suspected diagnosis of heart failure in the community

BACKGROUND

There is a common assumption that a normal ECG or a normal heart size on chest X-ray virtually rules out a diagnosis of heart failure.

AIMS

To assess the value of the electrocardiogram and chest X-ray in identifying patients with chronic heart failure in the community.

METHODS AND RESULTS

This study was a secondary analysis of data prospectively collected at the time of patient's enrollment in the EPICA study, an epidemiological study of the prevalence of heart failure in Portugal. A total of 6300 subjects were clinically evaluated. Patients who presented with symptoms or signs of heart failure, and/or were receiving diuretics for chronic heart failure (CHF) had a chest X-ray, ECG, and echocardiogram. The diagnosis of heart failure was confirmed in 551 cases. Patients with right atrial enlargement, atrial flutter, atrial fibrillation, 2nd degree-Mobitz I atrioventricular block, 1st degree atrioventricular block, left bundle branch block, lung interstitial oedema, and bilateral pleural effusion were more likely to be diagnosed with heart failure. For the diagnosis of heart failure, in the Portuguese population aged over 25 years, an abnormal electrocardiogram had an estimated sensitivity of 81%, and negative predictive value of 75%; an abnormal chest X-ray had an estimated sensitivity of 57%, and negative predictive value of 83%. Twenty five percent of patients with CHF had a normal ECG or chest X-ray.

CONCLUSION

Our results show that electrocardiographic and roentgenographic features are not sufficient to allow heart failure to be reliably predicted in the community and support the recommendation that all patients with suspected heart failure should undergo echocardiography.

The diagnosis of heart failure in primary care: value of symptoms and signs

BACKGROUND

The value of symptoms and signs in the diagnosis of CHF has rarely been tested in large numbers of patients in the community. The aim of this study was to evaluate the importance of symptoms, signs, and past medical history in the diagnosis of CHF in primary care.

METHODS

Data on a sample of Portuguese men and women attending 365 primary care centres for any condition other than the treatment of acute infection, metabolic conditions or pregnancy were collected. All subjects who scored three or more points in the sum of categories one and two of the Boston questionnaire (history and physical examination) and those being treated for heart failure with loop or thiazide diuretics were considered to have possible heart failure and referred for further assessment including a resting echocardiogram. The sensitivity, specificity, positive predictive value, negative predictive value and likelihood ratio (LR) for the diagnosis of heart failure were calculated.

RESULTS

A total of 5434 subjects were identified, of whom 1058 fulfilled the criteria for further assessment; 551 subjects had cardiac dysfunction at rest, of which 35.5% were in NYHA class I and 4.9% in class IV. Prior use of digoxin (LR 24.9) and/or diuretics (LR 10.6), a history of coronary artery disease (LR 7.1) or of pulmonary oedema (LR 54.2), were associated with a greater likelihood of having heart failure. Amongst current symptoms, a history of paroxysmal nocturnal dyspnoea (LR 35.5), orthopnea (LR 39.1) and breathlessness when walking on the flat (LR 25.8) were associated with a diagnosis of heart failure. However, these symptoms were not frequent amongst patients with heart failure within this population (sensitivity <36%). Jugular pressure > 6 cm with hepatic enlargement, and oedema of the lower limbs (LR 130.3), a ventricular gallop (LR 30.0), a heart rate above 110 bpm (LR 26.7), and rales at pulmonary auscultation (LR 23.3) were all associated with a diagnosis of heart failure, but were infrequent findings in patients with heart failure (sensitivity <10%).

CONCLUSIONS

Symptoms and signs, and clinical history had limited value in diagnosing heart failure when used alone. The signs and symptoms that best predicted a diagnosis of heart failure were those associated with more severe disease. If investigation is limited to patients with more definite symptoms and signs of heart failure, fewer than 50% of cases will be identified and a large number of patients with mild symptoms will be missed.

The epidemiological enigma of heart failure with preserved systolic function

BACKGROUND

Current epidemiological evidence suggests that the prevalence of preserved systolic function in patients with heart failure varies widely from 13 to 74%. This inconsistency suggests a lack of consensus as to what this condition really is and how it has been characterised for epidemiological studies.

AIMS

In this review, we summarise and discuss the current understanding of the epidemiology of heart failure with preserved systolic function and the challenges that this raises.

METHODS

Studies were identified from Medline and Embase Literature Database searches using the subject headings heart failure, diastolic heart failure, epidemiology, incidence, prevalence, diagnosis, prognosis and mortality.

RESULTS

Sixty-one studies of congestive heart failure with preserved systolic function were reviewed. There is great diversity in the criteria used to determine whether heart failure is present, the patient population, the setting of the study and methods of evaluating left ventricular function. This makes epidemiological studies of prevalence, morbidity and mortality impossible to compare.

CONCLUSIONS

The diagnosis of this syndrome might be better defined in terms of symptoms, elevated neuro hormones and impaired cardiac workload. This would allow accurate identification of cases so that further research could be conducted to measure outcome and assess therapeutic benefit.

Management of chronic heart failure in the community: role of a hospital based open access heart failure service

OBJECTIVE

To evaluate the role of an open access heart failure service based at a teaching hospital for the diagnosis and treatment optimisation of patients with heart failure in the community and to identify measures that may further enhance the effectiveness of such a service.

SUBJECTS

963 patients with suspected heart failure seen over an eight year period referred by their general practitioners to the cardiology department at a district general hospital.

MAIN OUTCOME MEASURES

Presence or absence of left ventricular systolic dysfunction (LVSD) (left ventricular ejection fraction < 50% on echocardiography), and determination of the risk factors and predictors of LVSD.

RESULTS

The majority of the patients were women (60% v 40%) and elderly (mean age 68.8 years). On echocardiography, only 30.8% were found to have LVSD. Patients were more likely to have LVSD if they were men (42.3% v 23.1%, p < 0.001, relative risk (RR) 1.8), were > 60 years of age (33.5% v 20.8%, p < 0.001, RR 1.6), or had a history of diabetes (49.4% v 29.1%, p < 0.001, RR 1.7), ischaemic heart disease (36.5% v 29.1%, p = 0.04, RR 1.3), or atrial fibrillation (52.6% v 27.8%, p < 0.001, RR 1.9). An abnormal ECG (48.4% v 19.5%, p < 0.001, RR 2.5) and cardiothoracic ratio > 0.5 on chest radiograph (44.3% v 17.8%, p < 0.001, RR 2.5) were found to be good predictors of LVSD. A normal ECG (negative predictive value 80.5%) and a cardiothoracic ratio of < 0.5 (negative predictive value 82.2%) can be used as baseline measures to identify patients with lower risk of developing LVSD (combined negative predictive value 87.9%).

CONCLUSIONS

An open access heart failure clinic is effective for the diagnosis and management of chronic heart failure in community based patients. The presence of risk factors and simple baseline tests can be used to identify patients with LVSD in the community. The introduction of a protocol based on these findings into a referral system can improve the efficiency and cost effectiveness of such a service.

Systematic review of open access echocardiography for primary care

Over the last few years there has been a revolution in open access echocardiography services due to an increased demand from within secondary care and primary care. There have been some concerns expressed by specialists and open access echocardiography has not been universally welcomed as a means of offering healthcare. Suspected heart failure comprises the majority of primary care referrals for open access echocardiography. There is lack of rigorously controlled studies to support widespread establishment of open access echocardiography services.

Heart failure management in the emergency department observation unit

The United States is currently in the midst of a heart failure epidemic. This has a tremendous impact on morbidity, mortality, and associated costs to our health care system. With demographic trends expected to double the at-risk cohort over the next 30 years, there is a serious need to develop more efficacious strategies addressing early diagnosis, treatment options, and outcomes in patients stricken with heart failure. This article reviews the newest diagnostics, therapeutics, and strategies for the management of heart failure and suggests appropriate implementation of these approaches in the emergency department observation unit.

Hypothetical economic analysis of screening for left ventricular hypertrophy in high-risk normotensive populations

BACKGROUND

Left ventricular hypertrophy (LVH) measured by echocardiography is a powerful independent marker of increased cardiovascular risk. The prevalence of echocardiographic LVH in patients with high cardiovascular risk appears to be high, even in patients currently considered normotensive.

AIM

To ascertain the likely costs of screening for and treating echocardiographic LVH in normotensive patients at high risk of cardiovascular events.

DESIGN

Hypothetical economic analysis.

METHODS

Cost analyses were based on known costs of echocardiography, costs of selected cardiovascular medications and prevalence of normotensive LVH in at-risk populations, combined with treatment effect data from studies of hypertensive patients with echocardiographic LVH.

RESULTS

Screening costs per case for echocardiographic LVH are likely to be low, because of the high prevalence of the condition and the low unit cost of echocardiography. Treatment costs are likely to be comparable to those currently deemed acceptable in treating high-risk cardiovascular populations, e.g. the HOPE study population.

DISCUSSION

The costs of screening for and treating LVH in normotensive patients at risk of cardiovascular events do not appear to be prohibitively high. Trials of screening and treatment for normotensive LVH seem therefore to be warranted.

Prevalence and predictors of heart failure with preserved systolic function: Community hospital admissions of a racially and gender diverse elderly population

BACKGROUND

The reported prevalence of preserved systolic function (PSF) heart failure (HF) varies widely and has not been well-studied in nonwhite patients. To estimate the prevalence of PSF HF resulting in hospital admission, we studied admissions to a large community hospital serving a racially diverse community.

METHODS

The charts of 300 consecutive patients > or =65 years old with a primary discharge diagnosis of HF were reviewed. In patients who met the Framingham criteria for HF diagnosis, an assessment of left ventricular function was obtained from review of chart data. Comparison of baseline characteristics and multivariate analysis of potential predictors of PSF HF was undertaken.

RESULTS

Of the 300 patients, 247 (82%) met the Framingham criteria for diagnosis of HF. Ninety-seven patients (39%) of these had PSF. Twenty (8%) of the diagnosed HF patients had a diagnosis of severe aortic or mitral valvular disease, 9 of whom had preserved systolic functions. Thus 88 (36%) of the HF patients had PSF HF likely resulting from diastolic dysfunction. On multivariate analysis, age, hypertension at presentation, peripheral edema, normal sinus rhythm and a history of coronary artery bypass grafting or coronary angioplasty were significantly associated with PSF HF rather than HF with reduced systolic function. Left bundle branch block or other intraventricular conduction delay was independently associated with reduced systolic function HF. However, because these findings occurred in patients with and without systolic dysfunction, none were pathognomonic of PSF HF.

CONCLUSION

In this racially diverse, majority nonwhite, cohort of older patients admitted for HF, the Framingham criteria for the diagnosis of HF were met in 82% of the patients. Of these, 39% had PSF HF and 36% had PSF HF in the absence of severe aortic or mitral valve disease, suggesting that diastolic dysfunction was etiologic. Although there was an independent association of PSF HF with a number of clinical characteristics, none of these characteristics was pathognomonic of preserved, versus reduced, systolic function HF.

N-terminal pro-brain natriuretic peptide for discriminating between cardiac and non-cardiac dyspnoea

AIM

Evaluation of N-terminal pro-brain natriuretic peptide (NT-proBNP) to confirm or disprove heart failure in community patients complaining of dyspnoea.

METHODS AND RESULTS

General practitioners referred 345 consecutive patients complaining of dyspnoea to our hospital-based clinic, where a diagnosis was established based on a combined programme for heart and lung diseases including echocardiography. The level of NT-proBNP in plasma was also measured. The mean (S.D.) concentration of NT-proBNP in patients with heart failure was significantly higher, 189 (270) pmol/l in patients with heart failure (n=81), than in patients with non-cardiac dyspnoea (n=264), 17 (38) pmol/l (P<0.001). In patients > or = 50 years NT-proBNP <11 pmol/l for men and <17 pmol/l for women excluded heart failure with a negative predictive value of 97% while the positive predictive value was 53%, the sensitivity 95% and the specificity 68%. Areas under receiver operator characteristic curves for men and women were 0.93 and 0.90, respectively.

CONCLUSION

In a relevant setting of primary care patients complaining of dyspnoea, NT-proBNP seems promising for disproval of heart failure, and this test may reduce the need for echocardiographic screening with 50%. However, the discrimination levels of NT-proBNP found in this study may need prospective confirmation, before the test can be generally recommended.

Epidemiology and clinical aspects of congestive heart failure

Congestive heart failure (CHF) is an increasing problem for healthcare systems in all developed countries. The prevalence is increasing partly due to ageing of the population, but also due to improved survival from acute cardiac disease such as myocardial infarction. Advances in diagnostic techniques and better understanding of the pathophysiology offer many opportunities for substantial improvement in the management of CHF. This article reviews the current epidemiology of CHF and the related diagnostic issues.

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.

Does a prolonged QT peak identify left ventricular hypertrophy in hypertension?

BACKGROUND

Left ventricular hypertrophy is a powerful predictor of death. Hypertensive subjects with left ventricular hypertrophy can have increased QT (end) dispersion, which is associated with cardiac death. Despite its prognostic value, QT (end) dispersion is not widely used. QTp (i.e. start of QRS to peak of T wave) is easier to measure. Therefore, we tested the hypothesis that long QT peak was associated with left ventricular hypertrophy and assessed its cost-effectiveness at diagnosing left ventricular hypertrophy.

METHODS

ECGs and echocardiograms were recorded in 47 hypertensive patients. The onset of the QRS complex and peak of T wave of lead I of each subject's ECGs were digitised by one observer blind to results of the echocardiogram. Receiver-operator characteristics curves were plotted to determine the sensitivity and specificity of different cut-off values of QT peak at predicting left ventricular hypertrophy (defined as left ventricular mass index> or =134 g/m2 in male, > or =110 g/m2 in female).

RESULTS

The heart-rate corrected QT peak of lead I correlated with left ventricular mass index (r=0.45, P=0.002). If all patients with a prolonged QT peak (> or =300 ms) had an echocardiogram, then no cases of left ventricular hypertrophy would be missed (100% sensitive). This novel ECG criterion not only had better positive and negative predictive values than the Sokolow-Lyon voltage criteria, but also resulted in more cost-effective resource use (< pound 370 vs. pound 1750/case of left ventricular hypertrophy detected).

CONCLUSION

If the results of this small pilot study are confirmed in larger studies, then measuring QT peak of lead I may become a cost-effective way of identifying hypertensives who are likely to have echocardiographic left ventricular hypertrophy.

Prevention and management of chronic heart failure in management of asymptomatic patients

Symptomatic heart failure is preceded by a somewhat prolonged asymptomatic stage in many patients. The number of patients with asymptomatic heart dysfunction is about 4-fold greater than the number of patients with clinically overt heart failure. Pharmacologic treatment with angiotensin-converting enzyme inhibitors and beta-blockers (in particular carvedilol) of asymptomatic patients with systolic left ventricular (LV) dysfunction can prevent or delay the occurrence of symptoms and reduce mortality in the long term. Thus, it would be of utmost importance to recognize and appropriately treat these patients before they develop heart failure symptoms. The cost-effectiveness of screening for asymptomatic heart dysfunction in the general population and in cohorts at risk has not been extensively evaluated. A normal electrocardiogram has a high negative predictive value in patients at risk. Echocardiography is the best tool for diagnosis and characterization of heart dysfunction, but extensive use is limited by availability and cost. Natriuretic peptides (brain natriuretic peptide and N-terminal pro-brain natriuretic peptide) are very sensitive markers of heart dysfunction and volume overload, and their measurement has been proposed as a first-line test to select patients who need echocardiography. The definition of the etiology of LV dysfunction--in particular, of the ischemic etiology--has prognostic and therapeutic implications. In addition to revascularization, pharmacologic treatment with antiplatelets and statins is helpful in preventing new ischemic events and the development of heart failure. The prevention, or at least the delay, of clinical manifestations of heart failure is strongly related to an effective approach to the asymptomatic stage. Therefore, it is important to educate the entire medical community, particularly physicians in the primary care setting, about recognition and treatment of these patients.

A randomised controlled trial of joint consultations with general practitioners and cardiologists in primary care

BACKGROUND

Joint consultation sessions of a small group of general practitioners (GPs) and a specialist in orthopaedics proved to be an effective way of decreasing the referral rate of orthopaedic patients. Cardiac complaints comprise an important category of health problems with high referral rates.

AIMS

To study the effects of joint consultation on the quality of care and referrals for patients with cardiac complaints.

DESIGN OF STUDY

Randomised controlled trial.

SETTING

Forty-nine GPs participated in 16 consultation groups, each with one of 13 cardiologists, in monthly joint consultations over a period of about 18 months.

METHOD

The GPs selected patients about whom they were uncertain, and those needing urgent referral were excluded. Patients were randomly assigned to joint consultation or to usual care. After a follow-up period all patients had a joint consultation for outcome assessment. Referral data were provided by two regional health insurance companies and questionnaires were given to the patients, GPs, and cardiologists to gauge their opinion of the trial.

RESULTS

One hundred and forty-eight patients in the intervention group and 158 patients in the control group fulfilled the whole protocol. The quality of care was similar in both groups. In the intervention group, 34% of the patients were referred, compared with 55% in the control group (P = 0.001), and fewer patients underwent further diagnostic procedures (7% compared with 16%, P = 0.013). Referrals to cardiology as a proportion of all referrals decreased in the practices of the participating GPs, compared with their reference districts (P = 0.024).

CONCLUSION

Joint consultation is an effective method that provides a quality of care that at least equals usual care and that contributes to a better selection of patients who need specialist care.

The frequency of systolic versus diastolic heart failure in an Egyptian cohort

BACKGROUND

All factors predisposing for congestive heart failure (CHF), such as coronary artery disease (CAD), hypertension and diabetes are increasing in prevalence in Egypt. Despite this, no data about CHF in our country are available.

AIMS

To study the relative contribution of systolic vs. diastolic heart failure in Egyptians and the prevalence of risk factors in this population, as well as their prognosis.

METHODS

This was a retrospective study of patients with a diagnosis of CHF over a 3.5-year period in a general cardiology clinic. Demographic, ECG and echocardiographic data for left ventricular systolic and diastolic function were collected. The differential effect of systolic versus diastolic CHF was analyzed regarding hospitalization and mortality.

RESULTS

After exclusion of valvular diseases, we found 155 patients diagnosed with heart failure, 102 patients (66%) had systolic heart failure, and 53 (34%) had diastolic heart failure. Mean age was 60+/-10 and 63+/-11 years, respectively (P=0.13). Systolic CHF patients had significantly more CAD, while those with diastolic failure were mostly hypertensives (P<0.01) for both. There was no significant difference in the incidence of diabetes mellitus, cerebrovascular accidents or atrial fibrillation between the two groups. Patients with systolic failure required more hospitalization, P<0.05, and had a mortality rate of 17.6% vs. 11.3% for patients with diastolic heart failure (P=0.3).

CONCLUSION

Diastolic heart failure is present in one-third of cases of CHF in Egyptians. Hypertension is very common in this group. These patients require less hospitalization but have a similar mortality rate.

Heart failure in primary care: qualitative study of current management and perceived obstacles to evidence-based diagnosis and management by general practitioners

BACKGROUND

Chronic heart failure is a common clinical condition with high morbidity and mortality. Despite the evidence that appropriate treatment with angiotensin-converting enzyme inhibitors can improve morbidity, primary care studies show that patients with heart failure are incorrectly diagnosed and inadequately treated.

AIM

To explore general practitioners' accounts of their management of patients with heart failure and identify the perceived obstacles to diagnosis and management.

METHODS

We conducted this qualitative study using semi-structured interviews in 18 general practices. The practices were stratified on the basis of size, location, and the level of practice development. The interviews were based on a schedule of open questions based on the literature on diagnosis and management of patients with heart failure. Transcriptions of the audiotaped interviews were independently analysed by two researchers and analysis was based on open coding using a constant comparative approach. Categories were reduced to major themes.

RESULTS

General practitioners suspect heart failure when patients present with breathlessness or ankle oedema. Many general practitioners reported that they would diagnose heart failure after respiratory examination and a positive finding of basal crepitations. Many general practitioners arrange a chest X-ray to establish the diagnosis and some arrange an electrocardiogram. A few general practitioners mentioned that they diagnosed heart failure with a trial of diuretics. Obstacles to diagnosis were mentioned by most general practitioners and included lack of facilities for appropriate investigations (especially echocardiography) and lack of time and expertise. Obstacles to management included lack of time, high cost of drugs, difficulty with diagnosis, selection bias towards younger patients and not having the confidence to initiate angiotensin-converting enzyme inhibitors. Many general practitioners were unaware of the impact angiotensin-converting enzyme inhibitors can have on morbidity and mortality.

CONCLUSIONS

Although symptoms of heart failure are not sufficiently specific for diagnosing patients with heart failure, many general practitioners in European countries treat people with suspected heart failure on the basis of symptoms and signs alone. This study has identified many obstacles to the diagnosis and management of heart failure that may explain why patients are inadequately managed in primary care. Specific implementation strategies need to be tailored to overcome these obstacles.