The Agency for Healthcare Research and Quality (formerly the Agency for Health Care and Policy Research), American College of Cardiology, American Heart Association, and European Society of Cardiology have all issued recommendations on the diagnosis and treatment of left ventricular systolic dysfunction, the most common type of heart failure. These recommendations provide a benchmark for measuring the quality of heart failure care and implementing improvements. They advise that patients with suspected or overt heart failure should undergo diagnostic testing to measure ventricular function and that those with ejection fractions <40% should receive angiotensin-converting enzyme (ACE) inhibitors. ACE inhibitors and |3-blockers should be titrated to the recommended doses to decrease mortality regardless of symptoms, while patients with concomitant atrial fibrillation should receive warfarin unless contraindicated.
Two large studies suggest that many hospitalized patients do not undergo measurement of left ventricular ejection fraction to determine the underlying cause of their heart failure, while a significant proportion of those with moderately to severely decreased left ventricular ejection fractions do not receive ACE inhibitors and P-blockers. Similarly, several studies show that warfarin is underused in atrial fibrillation.
The reasons for underusing recommended diagnostic tests and drugs are unclear. As recently as 1990, 83% of heart failure patients were being looked after by internists or primary care physicians with no formal cardiology training, and correspondingly less informed about recent therapeutic advances. Surveys assessing the use of heart failure diagnostic and management guidelines by board-certified cardiologists and board-certified primary care physicians show differences in patient care. The results suggest that some primary care physicians do not fully appreciate the difference between left ventricular systolic and diastolic dysfunction.
This lack of understanding of heart failure pathophysiology may explain why primary care physicians differ from cardiologists in their perception of the importance of measuring the left ventricular ejection fraction. They are significantly less likely to request this parameter. Many also appear not to differentiate between the different types of heart failure. They are more likely to prescribe digoxin when it is not indicated (diastolic dysfunction) and less likely to prescribe digoxin and ACE inhibitors when they are indicated.
National guidelines have emphasized the safety and importance of ACE inhibition in patients with asymptomatic low blood pressure and those with mild renal insufficiency. The surveys suggest that primary care physicians underuse ACE inhibitors because they overestimate the risk rather than fail to appreciate the benefits. Similarly, they are significantly less likely than cardiologists to prescribe warfarin for patients with concomitant atrial fibrillation because they overestimate the risks of anticoagulation.
Primary care physicians are likely to continue to manage the majority of patients with heart failure. An improved quality of primary care should be a priority for this highly prevalent condition. Unfortunately, studies have shown that the development and dissemination of guidelines may increase knowledge and modify attitudes, but has little impact on behavior and, ultimately, on outcome. Primary care physicians need further education on heart failure pathophysiology, the safety of ACE inhibitors and [3-blockers, and the low risk of major bleeding with anticoagulation in selected patients.
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management; caregiver specialty; primary care physician; cardiologist; guideline; diagnostic test; drug