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European Journal of Heart Failure 1999 1(4):407-410; doi:10.1016/S1388-9842(99)00053-7
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© 1999 European Society of Cardiology

Diagnostic tests, treatment and follow-up in heart failure patients — is there a gender bias in the coherence to guidelines?

Märit Mejherta,*, Jan Holmgrenb, Per Wändellc, Hans Perssona and Magnus Ednera

a Section of Cardiology, Division of Internal Medicine, Karolinska Institute, Danderyd Hospital 18288 Danderyd, Sweden
b Haninge Läkarmottagning Stockholm, Sweden
c Husläkarmottagningen Österåker Stockholm, Sweden

* Corresponding author. Tel.: +46-8-6556404; fax: +46-8-6226810


   Abstract
Top
 Abstract
1. Background
 2. Methods
 3. Results
 4. Discussion
 References
 
Aims: To relate clinical data in a consecutive cohort of patients admitted with heart failure in Sweden to demographic data and the use of diagnostic tests, medical treatment, care process and mortality.

Methods and results: Retrospective investigation of all charts concerning patients discharged with primary diagnosis of heart failure in two Swedish hospitals during the second half of 1995 was undertaken. Records from 187 men and 192 women were analyzed, median age was 78 years. During hospital stay 75% of the patients, regardless of gender, were examined with chest radiography. Echocardiography was performed in 59% of all patients, more often in men than in women (68% vs. 55%, P < 0.011). The proportion of patients receiving ACE-inhibitors was higher if echocardiography had been performed, in both men (38% vs. 72%, P < 0.001) and women (38% vs. 55%, P < 0.033). Mean hospital stay was 6.4 days. After discharge 57% of the patients were referred to the general practitioners (GP), 21% to the hospital outpatient clinic. Young age (P < 0.001), male gender (P < 0.01) and treatment with β-blocking agents (P < 0.035) were independently related to referral to hospital outpatient clinic. Within the group referred to the GPs, 62% of the patients had a follow-up visit within 3 months after discharge while 49% had visited the hospital outpatient clinic. The 1-year mortality rate was high, 30%.

Conclusion: Patients admitted with heart failure in Sweden are old and carry a poor prognosis. In spite of the poor prognosis, only approximately half of the patients are followed-up within 3 months after discharge. There is, in contrast to practice guidelines, an underuse of diagnostic tests of left ventricular function and medical treatment is often suboptimal. These unsatisfactory findings were more pronounced in women.

Key Words: Heart failure • Care process • Gender difference • Guidelines

Received February 12, 1999; Revised July 5, 1999; Accepted August 9, 1999


   1. Background
Top
 Abstract
 1. Background
2. Methods
 3. Results
 4. Discussion
 References
 
Increasing prevalence, poor health-related quality of life and adverse prognosis are important aspects of the increasing burden of heart failure in society [1–6]. These factors advocate the need for studies on the use of diagnostic tests, treatment and analysis of the care process in heart failure patients. Several studies have pointed out the difficulties in diagnosing heart failure [7–9]. When treating heart failure there is still an underuse of ACE-inhibitors [10,11] contrasting the recommendations of The European Society of Cardiology [12]. The main purpose of our study was to describe the use of diagnostic tests, treatment and follow-up of patients admitted with heart failure to two Swedish hospitals, and to analyze possible differences in these aspects concerning age and gender.


   2. Methods
Top
 Abstract
 1. Background
 2. Methods
3. Results
 4. Discussion
 References
 
The investigation conforms with the principles outlined in the Declaration of Helsinki. The study was carried out in two hospitals in Stockholm, one central county hospital and one district county hospital, the catchment areas corresponding to a population of 425 000 inhabitants. We included all 379 patients admitted and discharged at either hospital with heart failure as the primary diagnosis (the Ninth Division of the International Classification of Diseases Code, ICD 428 A, B, X) in the second half of year 1995. Most patients had previously known heart failure. Readmissions were considered as well as first admissions. All patient charts from within 3 months after discharge were obtained. Two patients were lost to follow-up as they moved away from Stockholm. Information concerning demographics, etiology, previous history of heart failure, Killip class, diagnostic tests, treatment, care process including readmissions were obtained from the charts. Information of mortality was collected from Statistics Sweden. The results from the two hospitals did not differ and were analyzed as a whole. Non-invasive cardiac procedures included chest radiography and echocardiography. These data were collected from hospital records only. Data on follow-up visits were collected from hospital charts as well as from charts of the GPs. Data on chest radiography was included only if the X-ray was performed during the index hospital stay, echocardiography, however, if performed at index hospital stay or within the previous 2 years.

The study was performed in cooperation with the National Board of Health in Sweden and approval from the Ethics Committee was therefore not a prerequisite.

2.1. Statistical analysis
All values are expressed as mean±S.D. unless otherwise stated. Categorical data were analyzed using a {chi}2-test with correction according to Yates. The continuous data were evaluated using Mann–Whitneys signed-rank test. Spearman’s correlation coefficients are given when appropriate. A stepwise logistic regression model was used to assess the predicted value of various baseline variables for the actual care process. A P-value <0.05 was considered significant


   3. Results
Top
 Abstract
 1. Background
 2. Methods
 3. Results
4. Discussion
 References
 
3.1. Patient characteristics
Baseline characteristics are defined in Table 1. Median age in men was lower, 78 years (range 35–95), compared to that in women, 81 years (range 40–99) (P<0.001). According to Official Statistics in Sweden 1991–1995 life expectancy in women aged 81 was 7.98 years and in men aged 78, 7.67 years. The distribution of gender was equal. No significant differences existed between genders concerning etiology, Killip class at arrival to the hospital or whether the heart failure was previously known or not.


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  		Table 1 Baseline characteristics (N=379)

 
3.2. Investigation and treatment
Table 2 shows the frequency of chest radiography, no difference was found with regards to gender. There was a difference between genders in the use of echocardiography. Our data showed that echocardiography was obtained in 68% of men, 55% of women (P<0.01). We found a correlation between the use of echocardiography and the use of ACE-inhibitors. If echocardiography had been performed, the proportion of men prescribed ACE-inhibitors increased from 38% to 72% (P<0.001), the proportion of women from 38% to 55% (P<0.033). As shown in Table 3, medication differed between genders as women were more often prescribed digoxin, men ACE-inhibitors. Both groups were treated with high doses of diuretics. There was a discrepancy in the prevalence of atrial arrhythmia and the use of oral anticoagulants as 50% of the patients were reported to suffer from atrial flutter/fibrillation but only 20% were put on oral anticoagulants. In Sweden, however, many elderly patients, in our study 34–35% of all, are put on Aspirin in stead of Warfarin.


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  		Table 2 Radiography, echocardiography

 


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  		Table 3 Medication

 
3.3. Care process
Most patients, 93.4%, were admitted to the hospital wards via the emergency room, ER. A minority, 6.6%, was admitted directly to a hospital ward. In spite of most patients, 77%, having a previous diagnosis of heart failure only 38% brought a note of referral to the ER. Mean hospital stay was 6.4 days (range 1–54 days) regardless of gender. Mean hospital stay did not change if patients who died during the index hospital stay were excluded. Most patients were discharged to follow-up by a generalist, 57%, while 21% were planned to get a follow-up visit at the hospital outpatient clinic. Some patients, 10%, were referred to the geriatric clinic, 11% to private specialists or other health care institutes.

Table 4 shows the differences between the cohort (A) discharged to general practitioners (GP) vs. the cohort (B) discharged to follow-up at the hospital outpatient clinic. The proportion of men in (A) 44%, was significantly lower than in (B) 71% (P<0.001). Mean age in (A) was, compared to (B), significantly higher in both sexes (P<0.001). There was a difference in the use of ACE-inhibitors. Fewer patients in (A) 53%, were put on this treatment than in (B) 76%, (P<0.001). Treatment with β-blockers was less frequent in (A), 31%, compared to (B), 51% (P<0.003). In a multivariate analysis we found that low age (P<0.001), male gender (P<0.01) and treatment with β-blockers (P<0.035) were independent predictors of follow-up at the hospital outpatient clinic.


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  		Table 4 Discharge pattern after hospital stay

 
3.4. Follow-up and readmission
In cohort (A) 62% of patients returned for check-up at their GPs within 3 months after discharge, compared to 49% in cohort (B) who returned to the outpatient clinic. Many patients were readmitted to the hospital within 3 months after discharge, 11% because of heart failure, some at several occasions, while 9% were readmitted due to other illness.

3.5. Mortality
As shown in Fig. 1, 12 patients died during hospital stay (3.2%), 58 patients (15.3%) died within 3 months after discharge. Within 6 months 83 patients (22%) died, 24% of the men and 13% of the women (P<0.012). One-year mortality was 30%. The data was also analyzed after subdividing it into age-related cohorts of men and women with a cut off age of >75 years. This did not change the results described above.


Figure 1
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  		Fig. 1 The survival rates with respect to gender distribution in patients admitted with heart failure within 1 year after discharge from hospital. Total number of patients, n=379, male=187, female=192.

 

   4. Discussion
Top
 Abstract
 1. Background
 2. Methods
 3. Results
 4. Discussion
References
 
The patients in our study were old and had high mortality rates, probably representative of the Swedish heart failure population. Average hospital stays were short and an accurate evaluation of heart function not always performed. You could expect these patients to have a follow-up visit soon after discharge, this however, was not the case in most patients. If echocardiography had been carried out, the probability of treatment with an ACE-inhibitor increased.

The prevalence of heart failure is equally distributed between genders. Incidence and mortality rates seem to be higher in men [4]. To explain this, it has been suggested that women may have a different etiology than men, more often suffering from hypertension than ischemic heart disease and thus more prone to diastolic dysfunction and a better prognosis. Also, overdiagnosing heart failure may be more common in women. This, however, does not explain why women, as in our study, more seldom were examined with echocardiography in the first place! The data of our study, being retrospective, must be interpreted with care. Still it is important to notice that there were shortcomings in the use of diagnostic tests, treatment and follow-up in heart failure patients and that this lack in coherence to guidelines seemed to be more pronounced in women.


   Acknowledgements
 
Peter Valverius, MD, PhD, for statistical analysis.


   References
Top
 Abstract
 1. Background
 2. Methods
 3. Results
 4. Discussion
 References
 

  1. McMurray J., McDonaugh T., Morrison C.E., Dargie H.J. Trends in hospitalization for heart failure in Scotland. Eur Heart J (1993) 14:1158–1162.[Abstract/Free Full Text]
  2. Eriksson H. Heart failure: a growing public health problem. J Intern Med (1995) 237:135–141.[Web of Science][Medline]
  3. Gillum R.F. Epidemiology of heart failure in the United States. Am Heart J (1993) 26:1042–1047.
  4. Ho K.L., Anderson K.M., Kannel W.B., et al. Survival after the onset of congestive heart failure in Framingham heart study subjects. Circulation (1993) 88:107–115.[Abstract/Free Full Text]
  5. Fryback D.G., Dasbach E.J., Klein R., et al. The Beaver Dam Health Outcomes Study: initial catalog of health-state quality factors. Med Decis Mak (1993) 13:89–102.[CrossRef]
  6. Rector T.S., Francis G.S., Cohn J.N. Patients self-assessment of their congestive heart failure. Heart Fail (1987) 3:192–196.
  7. McDonagh T.A., Morrison C.E., Lawrence A., et al. Symptomatic and asymptomatic left-ventricular dysfunction in an urban population. Lancet (1997) 350:829–8339.[CrossRef][Web of Science][Medline]
  8. Remes J., Miettinen H., Reunana A., Pyorala K. Validity of clinical diagnosis of heart failure in primary health care. Eur Heart J (1991) 12:315–321.[Abstract/Free Full Text]
  9. Dahlström U., Boman K., Edvardsson N., Pehrsson K., Persson S. Hjärtsvikt — en svårställd diagnos. Läkartidningen (1995) 92:1360–1363.[Medline]
  10. Clarke K.W., Gray D., Hampton J.R., et al. Evidence of inadequate investigation and treatment of patients with heart failure. Br Heart J (1994) 71:584–587.[Abstract/Free Full Text]
  11. Hillis G., Trent R., Winton P., et al. Angiotensin converting enzyme inhibitors: are we ignoring the evidence? Q J Med (1996) 89:145–150.
  12. The Task Force of the Working Group on Heart Failure of the European Society of Cardiology: The treatment of heart failure, Eur Heart J 18 (1997) 736–775.

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