[Heart failure: a view from primary care]

Prevalence of Chronic Heart Failure, Associated Factors, and Therapeutic Management in Primary Care Patients in Spain, IBERICAN Study

BACKGROUND

The prevalence of chronic heart failure (CHF) in patients assisted in primary care is not well known. We investigated the prevalence of CHF, its associated factors, and its therapeutic management.

METHODS AND FINDINGS

This was a cross-sectional, multicenter study conducted in primary care (PC) in baseline patients of the IBERICAN study (Identification of the Spanish Population at Cardiovascular and Renal Risk). CHF was defined as the presence of this condition in the medical history, classifying patients according to the type of ventricular dysfunction in CHF with preserved ejection fraction (pEF), or CHF with reduced ejection fraction (rEF). Clinical characteristics, relationship between CHF and main cardiovascular risk factors (CVRF), and drug treatments used according to ejection fraction (EF) were analyzed.

RESULTS

A total of 8066 patients were included (54.5% women), average age (SD) was 57.9 (14.8) years, of which 3.1% (95% CI: 2.3-3.7) presented CHF, without differences between men and women. CHF with pEF (61.8%; 95% CI: 55.5-67.6) was more frequent in women, and CHF with rEF (38.1%; 95% CI: 33.2-45.5) (p = 0.028) was similar in both genders (65.9%; 95% CI: 57.1-73.4 vs. 57.3%; 95% CI: 47.7-65.8) (p = 0.188). A progressive increase of the prevalence with age (15.2% in ≥80 years) and with the aggregation of CVRF was observed. The most prescribed treatments were beta-blockers (54.7%) followed by angiotensin converting enzyme inhibitors (42.8%) and angiotensin II receptor antagonists (41.3%), without differences between pEF and rEF. The variables that are most associated with the probability of suffering CHF were a personal history of left ventricular hypertrophy (OR: 5.968; p < 0.001), of atrial fibrillation (OR: 3.494; p < 0.001), and of peripheral vascular disease (OR: 2.029; p < 0.001).

CONCLUSIONS

Three in every 100 patients included in the IBERICAN study presented CHF, of which two thirds had pEF. The condition increased exponentially with age and aggregation of CVRF. We did not find any differences in drug treatment according to the type of ventricular dysfunction. The treatment of HF with rEF has much room for improvement.

Self-Care Practices of Primary Health Care Patients Diagnosed with Chronic Heart Failure: A Cross-Sectional Survey

Chronic heart failure patients require self-care behaviors and active monitoring of signs and symptoms to prevent worsening. Most patients with this condition are attended in primary healthcare centers. This study aimed to evaluate the endorsement of and adherence to self-care behaviors in primary health care patients with chronic heart failure. We conducted a multicenter cross-sectional study. We randomly included chronic heart failure patients from 10 primary healthcare centers in the Barcelona metropolitan area (Spain). Patients completed the European Heart Failure Self-Care Behaviour Scale, a health literacy questionnaire. Differences between groups were studied using ANOVA tests. We included 318 patients with a mean age of 77.9 years, mild limitations in functional activity New York Heart Association scale (NYHA) II = 51.25%), and a low health literacy index of 79.6%. The endorsement of self-care behaviors was low in daily weighing (10.66%), contacting clinicians if the body weight increased (22.57%), and doing physical exercise regularly (35.58%). Patients with lower educational levels and a worse health literacy had a lower endorsement. The screening of individual self-care practices in heart failure patients might improve the clinician follow-up. We suggest that primary healthcare clinicians should routinely screen self-care behaviors to identify patients requiring a closer follow-up and to design and adapt rehabilitation programs to improve self-care.

[Heart failure in primary care: Attitudes, knowledge and self-care]

OBJECTIVE

To determine the attitudes, knowledge, and self-care practices in patients with heart failure (HF) in Primary Care, as well as to identify factors associated with better self-care.

DESIGN

Cross-sectional and multicentre study.

SETTING

Primary Care.

PARTICIPANTS

Subjects over 18 years old with HF diagnosis, attended in 10 Primary Health Care Centres in the Metropolitan Area of Barcelona.

MAIN MEASUREMENTS

Self-care was measured using the European Heart Failure Self-Care Behaviour Scale. Sociodemographic and clinical characteristics, tests on attitudes (Self-efficacy Managing Chronic Disease Scale), knowledge (Patient Knowledge Questionnaire), level of autonomy (Barthel), and anxiety and depression screening (Goldberg Test), were also gathered in an interview. A multivariate mixed model stratified by centre was used to analyse the adjusted association of covariates with self-care.

RESULTS

A total of 295 subjects (77.6%) agreed to participate, with a mean age of 75.6 years (SD: 11), 56.6% women, and 62% with no primary education. The mean self-care score was 28.65 (SD: 8.22), with 25% of patients scoring lower than 21 points. In the final stratified multivariate model (n=282; R2 conditional=0.3382), better self-care was associated with higher knowledge (coefficient, 95% confidence interval: -1.37; -1.85 to -0.90), and coronary heart disease diagnosis (-2.41; -4.36: -0.46).

CONCLUSION

Self-care was moderate. The correlation of better self-care with higher knowledge highlights the opportunity to implement strategies to improve self-care, which should consider the characteristics of heart failure patients attended in Primary Care.

[Survival of patients with heart failure in primary care]

OBJECTIVE

To describe survival of patients with chronic heart failure (HF) followed up in primary care (PC) and analyse the effect of sex, age, clinical and health services factors, and income levels on survival.

DESIGN

Longitudinal observational study of a retrospective cohort of patients with information extracted from electronic medical records.

SETTING

PC Area 7 of the Community of Madrid.

PARTICIPANTS

Patients 24 year and older with at least one visit to PC in 2006.

PRINCIPAL MEASUREMENT

Incident cases of HF followed up from 2006 to 2010 or until death. Survival analysis with Kaplan-Meier and Cox proportional hazard multivariate regression.

RESULTS

A total of 3,061 cases were identified in a cohort of 227,984 patients. The survival rate was 65% at 5 years, with 519 patients dying with a median survival of 49 months. Factors associated with increased risk of mortality were, age (HR=1.04, 1.03-1.05), and having a diagnosis of ischemic heart disease (HR=1.45, 1.15- 1.78), or diabetes (HR=1.52, 1.17-1.95). Factors with a significant protective effect were: female sex (HR=0.72, 0.59-0.86), non-pensioner (HR=0.43, 0.23-0.84), having received the influenza vaccine annually (HR=0.01, 0.00-0.06), prescribed lipid-lowering drugs (HR=0.78, 0.61-0.99) or ACE inhibitors (HR=0.73, 0.60-0.88), and blood tests having been requested (HR=0.97, 0.95-1.00), X-rays (HR=0.81, 0.74-0.88), or electrocardiograms (HR=0.90, 0.81-0.99) in PC.

CONCLUSIONS

Data from patients with HF followed up in PC indicate that their survival is better than that obtained in other countries, supporting the argument of a better evolution of HF in Mediterranean countries.

[Treating COPD in chronic patients in a primary-care setting]

The aging of the populations in Western countries entails an increase in chronic diseases, which becomes evident with the triad of age, comorbidities and polymedication. chronic obstructive pulmonary disease represents one of the most important causes of morbidity and mortality, with a prevalence in Spain of 10.2% in the population aged 40 to 80. In recent years, it has come to be defined not only as an obstructive pulmonary disease, but also as a systemic disease. Some aspects stand out in its management: smoking, the main risk factor, even though avoidable, is an important health problem; very important levels of underdiagnosis and little diagnostic accuracy, with inadequate use of spirometry; chronic patient profile; exacerbations that affect survival and cause repeated hospitalizations; mobilization of numerous health-care resources; need to propose integral care (health-care education, rehabilitation, promotion of self-care and patient involvement in decision-making).