Heart failure (HF) is currently the only one of the cardiovascular syndromes with profound public health implications whose incidence is on the rise. The increase can be traced to aging of the population and the increased survival of patients with ischemic heart disease. The prevalence of HF in the general population is estimated at 0.5% to 2%, and increases to 6% in persons older than 65 years and to as much as 10% among those older than 75 years. In the last 15 years the prevalence of HF has doubled, and this trend will continue in the coming years.1
In Spain, HF causes around 20% of all deaths from cardiovascular disease and is the most frequent reason for hospitalization among persons older than 65 years. The number of hospital admissions for HF has increased by more than 70% since 1980, from 42 965 admissions/year to 73 448 admissions/year in 1993.2
Although the most common causes of this syndrome are hypertension and ischemic heart disease, any cause that chronically alters heart function (e.g., structural heart disease, valve disorders and diseases of the pericardium or great vessels) can lead to HF. Heart failure per se should not be taken as a final diagnosis, as there must exist an underlying disease--generally a structural heart disease. The prognosis for HF depends on appropriate management and treatment, although the presence of ventricular dysfunction per se indicates an unfavorable prognosis.
Overall mortality from this syndrome at 5 years after the initial diagnosis is 50%, a figure that has remained practically unchanged in recent years despite advances in medical treatment. Although the treatment regimens for HF are well established and the favorable effects of certain drugs on the prognosis are well known, fewer than 50% of the patients receive appropriate treatment according to evidence-based medical criteria.3 Only about one-third of all patients are given an electrocardiogram as part of the initial evaluation of HF, a shortcoming that has also been documented in Spain.4 The underuse of echocardiography in the initial diagnosis makes it difficult to detect those patients with systolic ventricular dysfunction, and hence delays appropriate treatment.
Heart failure is a clinical syndrome that is much more common in the elderly or very elderly. Mean age of the patients in the study by Soriano Palacios et al. published in this issue of Atención Primaria was 75 years; 57% of the patients were women. In a large hospital register assembled by internal medicine specialists --the SEMI-IC register5-- mean age was 77 years and the sex distribution was the same as in the report by Soriano Palacios et al. In another study done within the primary care setting --the ICAP study6-- mean age was slightly lower at 72 years, 61% of the patients were women, and mean functional class was better. However, all studies reported a high rate of comorbidity (chronic obstructive lung disease, diabetes, renal failure, etc). This contrasts with data from clinical trials, including some of the most recent studies (e.g., CIBIS-II, MERIT-HF, RALES and ValHeFT), in which mean age was 62 years, men predominated (80%), and comorbidity (often an exclusion criterion in clinical trials) was low. The etiology of HF in patients included in clinical trials is mainly ischemic, whereas in patients with HF being treated in the community the most common etiology is hypertension, at least in Spain (a circumstance also reflected in the present study, in the ICAP study and in the SEMI-IC register).
The difference in profile between patients included in clinical trials versus those seen in daily practice is not a feature exclusive to HF, but is a rather common feature of cardiovascular diseases. However, this difference is likely to have a notable influence on decision making with regard to evidence-based pharmacological treatment for patients in the community. A clear and noteworthy example is the use of beta-blockers for chronic HF (carvedilol, bisoprolol and metoprolol); these drugs have shown an unequivocally positive impact on prognosis, reducing overall mortality by 30% in different trials and meta-analyses,7 and ameliorating morbidity and stability (i.e., readmission, functional class, etc). Paradoxically, beta-blockers are still currently used for fewer than 15% of all patients with HF.8 Perhaps, as the present study suggests, the classical assumption that these drugs are contraindicated in HF still persists. Further problems are posed by the process of introducing treatment with these drugs in daily practice: contraindications (relative and absolute), the advanced age of most patients, comorbidity, problems with dose titration (which must be done with great care, and only when the patient´s condition is stable), and finally the lack of coordination between specialized care (hospital or extrahospital services) and primary care. Implementing treatment with beta-blockers in most patients who are candidates for these drugs is a process that requires close, efficient coordination between the cardiologist or internal medicine specialist and the primary care physician. It will not be possible to extend treatment with beta-blockers to a suitable proportion of patients until primary care physicians are actively involved in follow-up. The HF units now in operation at some hospitals may start treatment with beta-blockers in certain selected patients, but the current magnitude of and future perspectives for the incidence of HF in the Western world require a multidisciplinary focus for this problem, and coordinated management of patients to optimize the clinical benefits.
A previous study found not only that beta-blockers were underused (possibly explainable, as the authors suggest, by the fact that the relevant studies had only just been published at the time), but also that the use of angiotensin-converting enzyme (ACE) inhibitors, considered the cornerstone of treatment for HF, was less than optimal. In many patients (33%) no echocardiogram (or any other test of ventricular function) had been done; the information provided by such tests is fundamental to determine whether systolic or diastolic dysfunction is present, to choose the best approach to therapy, to rule out potentially correctable causes of HF, and to arrive at a prognosis. Moreover, a large proportion of patients in the present study had normal systolic function (42%), a finding also reported in earlier studies and related with the higher prevalence of diastolic dysfunction in older patients.
Angiotensin-converting enzyme inhibitors and angiotensin receptor antagonists (ARA-II) were prescribed for 72% of the patients with a documented reduction in ejection fraction, as compared to 46% of the patients in whom ejection fraction was preserved. Several studies have shown that ACE inhibitors are underused in clinical practice, both in hospitals3,5 and in primary care.4 This is a problem that still awaits solution. In addition, the study by Soriano Palacios et al. shows that during the 18-month follow-up period, ACE inhibitors were the type of drug substituted or stopped most often, which they attribute in great measure to the adverse effects of these medications.
The poor prognosis of HF related with the syndrome itself, and--to a non --negligible extent (20%)-- with comorbidity, probably undermined enthusiasm for treatments that might not have been tolerated well. In any case the prognosis for HF is unfavorable, as noted in other studies and emphasized once again here. Although improving the prognosis is a prime goal of treatment, it is no less important to maintain or improve, if possible, the quality of life, and to prevent frequent hospital readmissions (38.5% of the patients).
In this connection the role of the family doctor in follow-up is crucial in maintaining the patient stable and living at home for as long as possible. The physician consulted most often after hospital discharge was the family doctor, followed by hospital out-patient staff (note, however, that 19% of the patients were participating in clinical trials). Follow-up was not handled by any one physician exclusively, but was shared with specialists in internal medicine or cardiology. The primary care service is a privileged vantage point for the follow-up of these patients, who will usually need close clinical surveillance with frequent dose adjustments (especially for diuretics). Also important in follow-up care are such simple elements as appropriate educational measures for patients and their families, including control of body weight and information aimed at optimizing treatment compliance.9
It is difficult to develop a fixed protocol for the clinical follow-up of all patients with HF. Most patients will require adjustments in the dose of ACE inhibitors (often, the optimum dose is not attained during the hospital stay, mainly because short stays do not allow enough time for this), and the dose of diuretics must also be adjusted as the patient´s symptoms are brought under control. In patients with functional class III-IV HF, low dose sprironolactone (12.5-25.0 mg/day) should be considered, although this requires close vigilance of renal function and serum potassium concentrations. The usefulness of periodic echocardiograms or chest x-rays in follow-up has not been established (except for decompensated patients, and only when the need for repeat tests is based on the clinical findings). However, the value of creatinin and potassium ion measurements (7 to 10 days after discharge initially, and after 2-3 months in patients who remain stable) is unquestioned. If there are no contraindications, patients who are stable should be evaluated for treatment with beta-blockers by clinicians trained in the use of these drugs, and such treatment should be coordinated in conjunction with the family physician.
