Management of heart failure in primary care (the IMPROVEMENT of Heart Failure Programme): an international survey

Summary

Background

Heart failure is a prevalent condition that is generally treated in primary care. The aim of this study was to assess how primary-care physicians think that heart failure should be managed, how they implement their knowledge, and whether differences exist in practice between countries.

Methods

The survey was undertaken in 15 countries that had membership of the European Society of Cardiology (ESC) between Sept 1, 1999, and May 31, 2000. Primary-care physicians' knowledge and perceptions about the management of heart failure were assessed with a perception survey and how a representative sample of patients was managed with an actual practice survey.

Findings

1363 physicians provided data for 11 062 patients, of whom 54% were older than 70 years and 45% were women. 82% of patients had had an echocardiogram but only 51% of these showed left ventricular systolic dysfunction. Ischaemic heart disease, hypertension, diabetes mellitus, atrial fibrillation, and major valve disease were all common. Physicians gave roughly equal priority to improvement of symptoms and prognosis. Most were aware of the benefits of ACE inhibitors and β blockers. 60% of patients were prescribed ACE inhibitors, 34% β blockers but only 20% received these drugs in combination. Doses given were about 50% of targets suggested in the ESC guidelines. If systolic dysfunction was documented, ACE inhibitors were more likely and β blockers less likely to be prescribed than when there was no evidence of systolic dysfunction.

Interpretation

Results from this survey suggest that most patients with heart failure are appropriately investigated, although this finding might be as a result of high rates of hospital admissions. However, treatment seems to be less than optimum, and there are substantial variations in practice between countries. The inconsistencies between physicians' knowledge and the treatment that they deliver suggests that improved organisation of care for heart failure is required.

Introduction

Findings of epidemiological studies suggest that there are 50 million people with suspected or confirmed heart failure in Europe and neighbouring countries.1, 2, 3, 4, 5 The diagnostic and treatment burden of this disorder is large. Heart failure is also malignant and costly, both in terms of morbidity and resources.6, 7 Importantly, treatment for heart failure is highly effective.⁸

The Working Group on Heart Failure of the European Society of Cardiology (ESC) published guidelines for diagnosis in 1995,⁴ updated in 2001,⁵ that recommended minimum requirements for the investigation of suspected heart failure. These guidelines drew attention to the inadequacy of diagnosis by clinical means alone, and the working group suggested that objective assessment of cardiac dysfunction, usually by echocardiography, should be done. In treatment guidelines from 1997, updated in 2001,⁵ the ESC recommended widespread use of both angiotensin-converting enzyme (ACE) inhibitors and β blockers to improve symptoms and prognosis.⁹ Despite these recommendations, results from recent studies suggest that many patients with heart failure are not receiving these agents.10, 11 Additionally, if ACE inhibitors and β blockers are prescribed, the dose is often below the range that has been shown to confer a mortality benefit.10, 12

In Europe, patients with heart failure are managed mostly in the community by primary-care physicians. Such physicians have a key role in early identification, adequate assessment, and optimum treatment of heart failure. However, few studies provide information about doctors' knowledge of the management of heart failure, and how this knowledge translates into clinical practice. The aim was to address these issues by undertaking a large international survey of clinical practice in primary care.