Impact of specialist care in patients with newly diagnosed heart failure: A randomised controlled study
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 Griffiths Rushcliffe Primary Care Group Dr. Linda Kandola Rushcliffe Primary Care Group Deborah Pearce Specialist Heart Failure nurse, QMC Louise Hodgson Specialist Heart failure nurse, QMC Sarah Hinchcliffe Specialist Heart Failure nurse, QMC
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