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

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Abstract

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 β 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.

Introduction

Several therapeutic agents reduce mortality and morbidity in patients with all grades of heart failure [1], [2], [3]. Despite treatment, the prognosis of heart failure patients remains poor, with 5-year mortality rates exceeding 50% in those patients with persistent symptoms [4]. Recurrent hospital admissions are common, occurring in up to half of this population within 6 months of an index admission [5], [6].

Making an accurate diagnosis and determining its aetiology is often difficult because of the non-specific signs and symptoms. A 12-lead ECG [7] and a transthoracic echocardiogram [8] are two well-established evaluation techniques for patients with suspected heart failure. Once the diagnosis is established, patients may be managed in a number of ways – by their general practitioners (GPs), by specialist heart failure nurses [10], [14] or in dedicated “heart failure clinics” within primary or secondary care.

There is evidence within secondary care, that dedicated heart failure services provide more focused care that improves patient outcome [10], [11], [12].

The role of these within primary care is as yet not established despite the fact that most patients with heart failure present in primary care [8]. The diagnosis and management of heart failure within this setting is essential to ensure appropriate therapy.

Section snippets

Objective

The aim of this study was to examine the impact of specialist intervention on heart failure management both in primary and secondary care.

The primary end-point was optimum prescription of medication for heart failure as defined by use of angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARB); β blockers and spironolactone as per the European society of Cardiology (ESC) [13] guidelines for management of chronic heart failure.

The secondary endpoint was a composite

Study design

This was a prospective randomised trial conducted from the Queens Medical Centre, University Hospital, Nottingham between June 2002 and June 2003.

Ethics

The study complies with the Declaration of Helsinki. Local Ethics Committee approval was sought and informed written consent was obtained from all patients recruited into the study.

Study protocol

Patients with suspected heart failure, based on the request card received from the GP referred for an open access echocardiogram were screened for inclusion in primary and

Results

A total of 386 outpatients (mean age 72 ± 10 years) with suspected heart failure were screened from June 2002 through to June 2003 (Fig. 1).

The most common causes for referral were shortness of breath in 318 (82%) and fluid retention in 179 (46%).

265 patients were reviewed in the community clinic and the rest (121) in hospital following referral for open access echocardiography.

273 (70.7%) were excluded as they had normal LV systolic function on echocardiogram.

1 patient died pre-randomisation and

Discussion

In this study, we explored the benefit and feasibility of a specialist heart failure clinic combined with open access echocardiography provided in primary care and secondary care. Most previous studies relate to patients with established heart failure. There is little data on the effects of intervention in patients with newly diagnosed symptoms.

Specialist intervention in patients hospitalised with heart failure is proven to improve outcome and reduce costs when potentially remediable factors

Conclusion

Specialist care in the community supported by heart failure nurses provides a useful bridge between primary and secondary care, allowing continued clinical assessment and appropriate titration of drug treatment as well as continued patient education [34].

Specialist care in heart failure results in higher rates of optimal prescribing, regardless of the service location.

Acknowledgements

Dr. Jeremy GriffithsRushcliffe Primary Care Group
Dr. Linda KandolaRushcliffe Primary Care Group
Deborah PearceSpecialist Heart Failure nurse, QMC
Louise HodgsonSpecialist Heart failure nurse, QMC
Sarah HinchcliffeSpecialist Heart Failure nurse, QMC

References (34)

  • A.P. Davie et al.

    Assessing diagnosis in heart failure: which features are of any use

    QJM

    (1997)
  • T.M. Wheeldon et al.

    Echocardiography in chronic heart failure in the community

    QJM

    (1993)
  • R. Willenheimer et al.

    Simplified echocardiography in the diagnosis of heart failure

    Scand Card J

    (1997)
  • M.W. Rich et al.

    A multi-disciplinary intervention to prevent the re-admission of elderly patients with chronic heart failure

    N Eng J Med

    (1999)
  • C.M.J. Cline et al.

    Cost effective management programme for heart failure reduces hospitalisation

    Heart

    (1998)
  • W.J. Remme et al.

    Task Force Report: Guidelines for the diagnosis and treatment of chronic heart failure

    Eur Heart J

    (2001)
  • Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure

    N Eng J Med

    (1991)
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