By Stuart Qualtrough
It is widely acknowledged that heart failure has reached epidemic proportions but are we doing enough?
Is diagnosis failing heart failure patients?|~||~||~|It is widely acknowledged that heart failure has reached epidemic proportions. Current figures estimate that chronic heart failure (CHF) currently affects approximately 18.5 million individuals globally and forecasts that this number may increase to 33.2 million by 2015, driven by aging populations and the much publicised diabetes and obesity epidemics.
Although heart failure is a common clinical syndrome — especially in the elderly — its diagnosis is all too often missed. Despite the difficulties inherent in diagnosing heart failure, recent research suggests the majority of physicians feel capable of diagnosing the condition directly without the need for further consultation or referral. This may be in part due to the number of efficient diagnostic tests available to guide physicians in their diagnosis.
The problem lies in that these tools currently appear to be underused. European Society of Cardiology (ESC) guidelines recommend the routine use of chest x-rays, electrocardiogram and echocardiograms. Although respondents claim to use these three diagnostic tests in almost all cases, research suggests that a lower proportion of patients are actually receiving them.
Echocardiograms are a powerful diagnostic test but they remain a limited resource in many hospitals with opinion leaders suggesting that certain physicians may no longer prescribe echocardiograms due to long waiting lists.
In addition, despite clinical evidence of the benefits of cardiac devices, their use remains limited in the majority of the major markets studied. Opinion leader research confirms the benefits of these cardiac devices and suggests that key barriers to their use are the cost of the therapies along with primary care physicians' limited knowledge and experience regarding these devices.
It has also been suggested that physicians are under-prescribing key anti-hypertensive drugs recommended for the treatment of heart failure.
Interestingly the most commonly prescribed drug treatment in Italy is a four drug combination, including an ACE inhibitor, a beta blocker, a diuretic and an aldosterone antagonist. This differs from the most commonly prescribed three-drug combination favoured elsewhere by the addition of an aldosterone antagonist, which may in part be responsible for the particularly high survival rates observed in Italy.
Some 50-70% of patients who are hospitalised for acute heart failure are re-hospitalisations as opposed to newly hospitalised patients. Furthermore, a high proportion of acute heart failure patients (25-50%) will be re-hospitalised for acute heart failure within the space of a year.
Interestingly, the most common cause of the initial hospitalisation and re-hospitalisation of acute heart failure patients is the acute decompensation of chronic heart failure. This suggests that the treatment of chronic heart failure may be insufficient to prevent chronic patients from progressing to acute heart failure and that once a patient is hospitalised, the treatment is sub-optimal.
The treatment of acute heart failure has considerable opportunity for newer approaches such as calcium sensitisers, vasopressin antagonists and endothelin receptor antagonists to make an impact.
It appears that despite increasing awareness of heart failure and improving treatment strategies, the limited access to important diagnostic tests and costly innovative therapies, along with cardiac devices and surgical interventions continue to represent a clear barrier to treatment. The cost constrained nature of many health services mean that the emphasis must be on cost-efficiency. Therefore, primary care physicians and cardiologists must be aware of the need for aggressive intervention to prevent heart failure and reduce its burden on patients and on society as a whole.