Prevalence of unrecognized heart failure in older persons with shortness of breath on exertion

Overdiagnosis of heart failure in primary care: a cross-sectional study

BACKGROUND

Access to echocardiography in primary care is limited, but is necessary to accurately diagnose heart failure (HF).

AIM

To determine the proportion of patients with a GP's diagnosis of HF who really have HF.

DESIGN AND SETTING

A cross-sectional study of patients in 30 general practices with a GP's diagnosis of heart failure, based on the International Classification of Primary Care (ICPC) code K77, between June and November 2011.

METHOD

Electronic medical records of the patients' GPs were scrutinised for information on the diagnosis. An expert panel consisting of two cardiologists and an experienced GP used all available diagnostic information, and established the presence or absence of HF according to the criteria of the European Society of Cardiology (ESC) HF guidelines.

RESULTS

In total, 683 individuals had a GP's diagnosis of HF. The mean age was 77.9 (SD 11.4) years, and 42.2% were male. Of these 683, 79.6% received cooperative care from a cardiologist. In 73.5% of cases, echocardiography was available for panel re-evaluation. Based on consensus opinion of the panel, 434 patients (63.5%, 95% confidence interval [CI] = 59.9 to 67.1) had definite HF, of which 222 (32.5%, 95% CI = 30.9 to 34.1) had HF with a reduced ejection fraction (HFrEF), 207 (30.3%, 95% CI = 29.0 to 31.6) had HF with a preserved ejection fraction (HFpEF), and five (0.7%, 95% CI = 1.2 to 2.6) had isolated right-sided HF. In 17.3% of cases (95% CI = 14.4 to 20.0), the panel considered HF absent, and in 19.2% (95% CI = 16.3 to 22.2) the diagnosis remained uncertain.

CONCLUSION

More than one-third of primary care patients labelled with HF may not have HF, and such overdiagnosis may result in inadequate patient management.

Fluid Management in Patients with Chronic Heart Failure

Congestion, or fluid overload, is a classic clinical feature of patients presenting with heart failure patients, and its presence is associated with adverse outcome. However, congestion is not always clinically evident, and more objective measures of congestion than simple clinical examination may be helpful. Although diuretics are the mainstay of treatment for congestion, no randomised trials have shown the effects of diuretics on mortality in chronic heart failure patients. Furthermore, appropriate titration of diuretics in this population is unclear. Research is required to determine whether a robust method of detecting - and then treating - subclinical congestion improves outcomes.

Cardiac imaging in the geriatric population: what do we think we know, and what do we need to learn?

Cardiac imaging plays an important role in coronary artery disease (CAD), congestive heart failure (HF) and valvular heart disease (VHD) in the elderly. Imaging defines the structure and function of the cardiac system, refining the understanding of patients' anatomy and physiology and informing a host of clinical care decisions, including prognosis. Yet there is a paucity of evidence to guide the rational use of many imaging modalities in patients of advanced age, a population with considerable clinical heterogeneity, high prevalence and burden of cardiovascular disease (CVD) and atypical presentations of CVD. This paper discusses important considerations for cardiac imaging for older adults, particularly in regard to CAD, VHD and HF, and then presents domains for future research to produce data that would inform clinical care guidelines, appropriate use criteria and imaging lab protocols to address the unique needs of the fast-growing elderly population.