Dr Nigel Watson describes an audit of patients with heart failure in his practice which led to improved investigation and monitoring of the condition
Chronic heart failure (CHF) affects 2% of the UK population and 8% of people over 65 years of age.1 The prevalence has been estimated at 0.6 per 1000 in patients below the age of 65, rising to 28 per 1000 in those aged over 65.
CHF often has a poor prognosis, with worse survival rates than for breast and prostate cancer.2 Annual mortality for patients with CHF ranges from 10% to more than 50%, depending on severity of the CHF.3
The prevention and management of coronary heart disease (CHD) is a major priority for the Government in the Health of the Nation document.4 CHD was also the subject of the Government's second National Service Framework for health.
CHD has been identified as a priority area in both the health authorities' and the primary care groups/trusts' health improvement plans (HImPs).
Patients with CHF form an important subgroup of patients with CHD. CHF is a well-recognised area within primary care that is poorly diagnosed and poorly managed. Until recently primary care practitioners were only able to access echocardiography through outpatient departments.
CHF is a syndrome and not a diagnosis or disease.5 A syndrome is simply a collection of symptoms and signs. The underlying diagnosis and aetiology must always be sought in patients presenting with heart failure.
Treatment will depend on aetiology, e.g. surgery for valvular disease and ACE inhibitor for left ventricular systolic dysfunction. It is also the reason why heart failure should not be recorded as the primary cause of death on a death certificate.
Although treatment with diuretics may not necessarily be needed long term, regular review and consideration of treating either the patient's CHF or coexisting hypertension with an ACE inhibitor are important factors.
Aims of audit
To ensure accurate diagnosis and optimum management for all patients with CHF. By this means we hope to be able to improve life expectancy in those patients.
A computer search of all patients' computer records was made in November 1999 and repeated in June 2000 and April 2001. All patients with a recorded diagnosis of heart failure (both left ventricular failure and congestive cardiac failure) and aged <75 years of age were identified.
These patients' computer records were then examined for the required data.
Criteria for audit
The criteria for audit are shown in Table 1 (below).
Table 1: Criteria for heart failure audit
|1. Patient on disease database||
|2. The records show that the patient with suspected heart failure has had an ECG as part of the routine investigations||
|3. The records show that the patient with suspected heart failure has characteristic symptoms of heart failure confirmed by:
(a) a positive chest X-ray and/or
(b) an echocardiogram
|4. The records show that the patient with suspected heart failure has had an echocardiogram if he/she has a cardiac murmur on clinical examination||
|5. The records show that the patient with heart failure has been commenced on a diuretic||
|6. The records show that the patient with left ventricular systolic dysfunction has been commenced on an ACE inhibitor unless there are contraindications||
|7. The records show that the patient's blood pressure has been recorded annually||
|8. The records show that the patient's blood pressure is controlled and <150/90mmHg||
Results of audit
The results of audit are summarised in Figure 1 (below).
Figure 1: Results of the audit
|Criteria||Nov 99||June 00||April 01||Standard|
|Total no. patients aged <75 years with heart failure||40||36||32|
|Total no. patients aged <75 years||10270||10130||10050|
|Diagnosed by history and echocardiogram and/or chest X-ray||78%||92%||97%||100%|
|If cardiac murmur, must have echocardiogram||100%||100%||100%||100%|
|Patient prescribed a diuretic||100%||100%||100%||100%|
|Currently prescribed a diuretic||75%||83%||84%||75%|
|ACE inhibitor unless contraindicated||68%||100%||81%||75%|
|Annual blood pressure recording||68%||78%||94%||90%|
|Blood pressure <150/90mmHg||48%||69%||84%||75%|
The initial results were presented to the practice and the following conclusions were made:
- The disease database reflected the fact that the practice is 'paperless' and enters all data on the computer.
- Patient monitoring had probably relied largely on symptom control and thought had not always been given to specific monitoring measures.
- Few patients had echocardiograms requested by primary care.
- Little assessment of overall cardiac risk was made.
- Many patients had coexisting cardiac risk factors, e.g. history of myocardial infarction or hypertension.
- Clarification of the criteria to confirm CHF syndrome was required.
Action taken as a result of the first audit (Nov 99)
- The results of the audit were fed back to the doctors and nurses.
- A practice protocol was agreed and distributed.
- All GPs were given open access to echocardiography.
- A call/recall system was developed for all patients with heart failure.
The care of patients with heart failure has been improved and demonstrated by the audit. A CHD clinic has only recently been established, and includes all patients with CHF.
The following were noted when reviewing the patients' records in April 2001:
- The confirmation of heart failure remains difficult. It is often suggested on X-ray findings, but still few patients are referred for echocardiograms.
- Patients admitted to hospital with symptoms related to suspected heart failure have all had an echocardiogram.
- Over the past 12 months there has been a significant increase in the use of low dose spironolactone (25mg) in patients with CHF.
- Compliance is an issue for patients. Patients are not aware of the potentially serious nature of their condition and the importance of ongoing management, particularly if the episode of heart failure was acute.
- It is difficult to differentiate between acute and chronic heart failure from patient records.
There is a need to update the practice guidelines for heart failure. The following areas need to be considered:
- Echocardiogram is now accepted as the investigation of choice and should be performed in all patients with suspected heart failure.
- Treatment with ACE inhibitors is an insufficient outcome measure in the audit of patients with heart failure – the use of adequate doses is more important. The trial evidence3 for decreased mortality for patients with CHF was based on target doses of ACE inhibitors, which are as large a dose as can be tolerated, i.e. enalapril 10–20mg twice daily. There is no evidence of reduced mortality with the use of smaller doses of ACE inhibitors.
- The established role of cardio-selective beta-blockers such as bisoprolol needs to be clarified in general practice.
- Department of Health. National Service Framework for Coronary Heart Disease. Chapter 6: Heart failure. London: DoH, March, 2000.
- Sanderson S. ACE inhibitors in the treatment of chronic heart failure: effect and cost effectiveness. Bandolier 1994; 1(8).
- The CONSENSUS Trial study group. Effects of enalapril on mortality in severe congestive heart failure: Results of the co-operative north Scandinavian enalapril survival study (CONSENSUS) N Engl J Med 1987; 316: 1429-35.
- Department of Health. The Health of the Nation: a strategy for health in England. London: DoH,1998.
- Scottish Intercollegiate Network. Diagnosis and Treatment of Heart Failure due to Left Ventricular Systolic dysfunction. SIGN Guidelines No. 35. Edinburgh: SIGN, 1999
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