How does heart failure treatment differ between primary care physicians and cardiologists?

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. Antoni MR, Beyth RJ, Covinsky KE, et al. Failure to prescribe warfarin to patients with nonrheumatic atrial fibrillation. J Gen Intern Med. 1996;11.713-720. Baker DW, Hayes RP, Massie BM, Craig CA. Variations in family physicians' and cardiologists' care for patients with heart failure. Am Heart J. 1999;138:826-834. Bath PM, Prasad A, Brown MM, MacGregor GA. Survey of use of anticoagulation in patients with atrial fibrillation. BMJ. 1993,307:1045. Chodoff P, Bischof RO, Nash DB, Laine C. The AHCPR guidelines on heart failure: comparison of a family medicine and an internal medicine practice with the guidelines and an educational intervention to modify behaviour. Clin Perform Qual Health Care. 1996;4:179-185. Heart failure treatment with angiotensin-converting enzyme inhibitors in hospitalized Medicare patients in 10 large states The Large State Peer Review Organization Consortium. Arch Intern Med. 1997,157:1103-1107. Konstarn MA, Dracup K, Baker DW, et al. Heart failure: evaluation and care of patients with left ventricular systolic dysfunction. Rjblication No. AHCPR 94-0612. Rockville, USA: Agency for Health Care Policy and Research, 1994. Krumholz HM, Wang Y, Parent EM, Mockalis J, Petrillo M, Radford MJ. Quality of care for elderly patients hospitalized with heart failure. Arch Intern Med. 1997,157:2242-2247 Keywords management; caregiver specialty; primary care physician; cardiologist; guideline; diagnostic test; drug [gallery ids=""]
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