How does heart failure treatment differ between internists and cardiologists?

Patients with congestive heart failure are not exclusively under the care of cardiologists. Indeed, the vast majority are managed by noncardiologists. Two surveys by the Italian Associazione Nazionale Medici Cardiologi Ospedalieri (ANMCO [National Association of Hospital Cardiologists]) compared characteristics, treatment, and outcome in heart failure patients admitted to Italian cardiology and internal medicine wards.

TEMISTOCLE

The Heart Failure Epidemiological Study FADOI (Fed-erazione delle Associazioni dei Dirigenti Ospedalieri Internisti [Italian Federation of Hospital Internal Medicine Physicians])-ANMCO in Italian People (TEMISTOCLE) analyzed 2127 consecutive patients admitted with congestive heart failure to cardiology and internal medicine departments over a 2-week period. Results were as follows:

OSCUR

The Outcome dello Scompenso Cardiaco in relazione all’Utilizzo delle Risorse (OSCUR) study in Liguria included 749 patients, most of whom (78%) were treated by internists. Those managed by cardiologists were more likely to undergo echocardiography (92% vs 37%), Holter monitoring (25% vs 3%), and exercise stress testing (20% vs 0.5%). At discharge, they were also more likely to receive [3-blockers (41% vs 4%), angiotensin-converting enzyme (ACE) inhibitors (100% vs 74%), and spironolactone (35% vs 6%), and in higher dosages than from internists. The numbers of patients receiving diuretics and digoxin did not differ. The patients managed by cardiologists were younger (70±9 years vs 79+1 years), more likely to be male, and more likely to have coronary artery disease (57% vs 45%). Those managed by internists were more likely to have diabetes, chronic obstructive pulmonary disease, atrial fibrillation, and renal failure. Mortality rates did not differ (10% vs 6%, respectively), although heart failure was more severe on admission in the patients managed by cardiologists__

Quality of life was low and survival poor: 5% of patients died in hospital, 15% died within 6 months, and 45% were readmitted within 6 months.

There were no significant interspecialty differences in the therapies recommended by national and international guidelines, except for (3-blockers and spironolactone, which were more often prescribed by cardiologists.

In-hospital and postdischarge mortality, and readmission rates, did not differ between specialties. The cardiology patients had more severe disease. The internal medicine patients were older, with higher rates of comorbidity (diabetes, chronic obstructive pulmonary disease, atrial fibrillation).

Continuity of care was suboptimal in patients discharged with a diagnosis of heart failure: only 56% were included in a follow-up program.

The study showed that cardiologists and internists treat different types of patient. Internists treat older patients with milder heart failure on admission, but greater comorbidity. Therapy differs lit- tie, except in the greater use of P-blockers and within a few years, P-blocker and spironolactone spironolactone by cardiologists. The OSCUR study prescribing rates will probably be similar in the was performed in 1998, TEMISTOCLE in 2000: two specialties.

Keywords

management; caregiver specialty; internist; cardiologist; drug; therapeutic strategy

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