© 2000 European Society of Cardiology
A Rapid Access Heart Failure Clinic provides a prompt diagnosis and appropriate management of new heart failure presenting in the community
a Cardiac Medicine, Imperial College School of Medicine, National Heart and Lung Institute Dovehouse Street, London SW3 6LY, UK
b Cardiology Research Group, Department of Medicine and Therapeutics, University of Aberdeen Polwarth Building, Foresterhill, Aberdeen AB25 2ZD, UK
* Corresponding author. Tel.: +44-20-7351-8855; fax: +44-20-7351-8856. E-mail address: k.fox{at}ic.ac.uk (K.F. Fox).
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Abstract |
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 Top Abstract 1. Introduction2. Methods3. Results4. Discussion5. ConclusionReferences |
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Background and aims: The diagnosis of heart failure is an important clinical problem and yet reported diagnostic accuracy in primary care is less than 50%. We established a Rapid Access Heart Failure Clinic (RAHFC) in a district general hospital serving a population of 292000 in SE London, UK, to diagnose and manage new cases of heart failure presenting for the first time in the community.
Methods: Patients with suspected new onset heart failure were referred by their Primary Care Physician without appointment for clinical assessment on the same or next working day. Assessment by a specialist registrar in cardiology included history, examination, chest X-ray, electrocardiogram (ECG) and echocardiogram. When a diagnosis of heart failure was made appropriate treatment, including angiotensin converting enzyme inhibitors (ACEI), was started.
Results: Over 15 months 383 patients were seen (0.4 cases/100000 population/weekday) 178/383 (46%) were considered to have definite or possible heart failure at the initial assessment in the RAHFC. A normal ECG (negative predictive value 94%) and chest X-ray virtually excluded the diagnosis of heart failure. After subsequent specialist investigations and follow-up, including a trial of therapy where appropriate, 101/383 (26%) were finally diagnosed as clinical heart failure. ACEI therapy was commenced in 56/57 (98%) of patients in whom it was considered appropriate.
Conclusion: The RAHFC provided rapid assessment, prompt diagnosis and early introduction of life prolonging therapy for patients presenting with suspected heart failure in the community.
Key Words: Heart failure • Diagnosis • Treatment
Received March 9, 2000; Revised May 17, 2000; Accepted June 20, 2000
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1. Introduction |
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TopAbstract1. Introduction2. Methods3. Results4. Discussion5. ConclusionReferences |
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Heart failure is a significant health care burden in the elderly, largely reflecting the frequency of coronary artery disease in economically developed countries [1,2]. The annual incidence of heart failure rises steeply with age to over 1% in those over 85 years old [3] and this clinical syndrome results in frequent patient hospitalisations and has a high mortality [4]. With the ageing of the population and the increasing proportion of survivors with coronary disease the burden of heart failure will continue to increase.
In primary care an accurate diagnosis of this clinical syndrome can be difficult in the absence of specialist investigations. A study from Finland showed the diagnosis of heart failure in the community is correct in less than 50% of cases when compared with a gold standard of specialist clinical assessment based on a clinical scoring system [5]. Another study showed that only 53% of patients receiving loop diuretics for presumptive heart failure had echocardiographic left ventricular dysfunction [6]. In our population study in West London, UK (The Hillingdon Heart Failure Study) only 47 out of 157 referrals (30%) to a heart failure clinic with suspected new heart failure fulfilled the case definition for heart failure [3]. However, an accurate clinical diagnosis can be made by a cardiologist based on a combination of history, examination, electrocardiogram (ECG), chest X-ray and echocardiogram; all of which can be performed quickly and accurately in the Cardiology Department of a district general hospital [7].
Although the prognosis of heart failure is poor, with a 1-year survival of 62% from our recent population-based study [8], there are therapies which reduce morbidity and mortality. These comprise angiotensin converting enzyme inhibitors (ACEI) [9], and more recently beta-blockade [10,11], and spironolactone [12]. Despite this evidence the use of ACEI remains low [13] (and the use of beta-blockers even lower), perhaps because general practitioners are reluctant to initiate treatment with powerful drugs in the community in patients who are usually seriously ill.
We established a Rapid Access Heart Failure Clinic (RAHFC) in the Cardiology Department of Bromley Hospital, in South East London, UK, to address this clinical problem [14]. The aims of the RAHFC were: (i) to provide a rapid diagnosis of heart failure in patients presenting for the first time in the community who did not require hospital admission; and (ii) to facilitate the early introduction of ACEI and other therapies as appropriate.
This paper describes the organisation of the RAHFC, the characteristics of patients seen, and discusses the role of a rapid access hospital based strategy for identifying and managing incident (new) heart failure in the community.
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2. Methods |
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TopAbstract1. Introduction2. Methods3. Results4. Discussion5. ConclusionReferences |
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2.1. Population
One hundred and fifty-one Primary Care Physicians (General Practitioners) work within 59 practices in Bromley Health Authority (BHA) in South East London, UK. Their combined patients constitute a population of 292 000.
2.2. Rapid Access Heart Failure Clinic (RAHFC)
All patients (no age limit) presenting to their General Practitioner (GP) with possible new heart failure, or to the Emergency Department with the same diagnosis but who did not require hospital admission, were eligible for referral to this new service. The clinic was based in the Cardiology Department and ran from 12.00 h until 16.00 h each weekday. Patients were seen as they arrived at the clinic; no appointment was needed. GPs would still admit patients who were seriously ill directly to hospital in the usual way, so the RAHFC assessed those cases who would normally have been managed in the community, without referral to the Emergency Department or the ‘on-call’ medical team. Patients with known heart failure were not eligible for the clinic and were referred to the Emergency Department or cardiology outpatients.
The patient was seen by the doctor running the clinic (KF) who took a history and did a clinical examination. A venous blood sample was taken for full blood count, electrolytes and creatinine, thyroid and liver function tests, total cholesterol and blood glucose plus other tests indicated by the clinical assessment. Patients then had trans-thoracic echocardiography (TTE) by the same doctor. This was performed using a Hewlett Packard Sonos 1000 machine. Standard parasternal and apical views utilising M-mode, 2D and Doppler modalities were obtained. All data were entered onto a Microsoft AccessTM database designed for the clinic.
The patient was then informed of the clinical diagnosis (where possible), management and follow-up plans. When definite heart failure was diagnosed ACEI therapy was initiated immediately. Facilities for a first test dose under supervision were available in the Cardiology Department. Small quantities of pre-packed drugs including an ACEI and a loop diuretic were kept in the clinic. New cases of heart failure, particularly those commenced on an ACEI were reviewed once only after a week or so to monitor progress and renal function. In other cases where there was diagnostic difficulty additional specialist investigations were undertaken, and in some patients a trial of therapy was given with follow up in one the main cardiology outpatient clinics. Most patients seen in the RAHFC were discharged to the care of their GP after their initial assessment.
A full report detailing the diagnosis, results of investigations and proposed management was sent to the GP, usually within 24 h of assessment.
2.3. Definition of heart failure
To make a diagnosis of heart failure patients had to have appropriate symptoms (shortness of breath, fatigue, fluid retention or any combination of these symptoms) with clinical signs of fluid retention (pulmonary or peripheral) in the presence of abnormal cardiac structure or function, as defined by the guidelines of the European Society of Cardiology [15]. If an element of doubt remained, a beneficial response to therapy for heart failure (e.g. a brisk diuresis accompanied by substantial improvement in breathlessness) was taken to confirm the diagnosis.
2.4. Data collection and statistical analysis
Data were double entered into a computerised database and discrepancies were resolved. Statistical analysis was performed using SPSS for WindowsTM software. Chi-squared tests were used for discrete variables and t-tests for (normally distributed) continuous variables.
The study conformed with the principles outlined in the Declaration of Helsinki.
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3. Results |
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TopAbstract1. Introduction2. Methods3. Results4. Discussion5. ConclusionReferences |
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The following results cover a 15-month period from 1 December 1996, when the clinic opened, until the 28 February 1998.
3.1. Clinic operation and characteristics of patients assessed
Three hundred and ninety-one patients were referred to the RAHFC. Of the referrals, 383 (98%) were appropriate to the clinic guidelines. The remainder included patients with known heart failure or with suspected new heart failure but from GPs outside the study area. This report is based on the 383 appropriate referrals.
The referral rate was 0.4/100 000 population/weekday. The number of cases seen each day varied from 0 to 5 (mean 1.2). There were no significant variations in attendance through days of the week or by month, although a small non-significant excess was seen in the early part of the week and during the winter months.
The characteristics of patients assessed are shown in Table 1.
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The median age of referrals was 75 years. One hundred and sixty-seven referrals (44%) were male (median age 74 years) and 216 (56%) female (median age 76 years). Breathlessness and swollen ankles were the commonest presenting symptoms. Male referrals were significantly more likely than female referrals to be a current or ex-smoker (74% vs. 40%, P<0.001), to have a past history of myocardial infarction (15% vs. 8%, P=0.04), and significantly less likely to describe ankle swelling (40% vs. 65%, P<0.001).
3.2. Diagnosis of patients assessed in the RAHFC
At the end of the RAHFC assessment cases were categorised as definite or possible heart failure, or not heart failure. Overall 178/383 (46%) of cases seen were considered after their RAHFC assessment to have heart failure. This included patients with possible heart failure in whom further specialist investigations, including a trial of therapy, were needed to establish the diagnosis. Finally, 101/383 (26%) patients fulfilled the definition of clinical heart failure (Fig. 1 and Table 2). Of male cases, 53/167 (32%) had heart failure compared with 48/216 (22%) of female cases (P=0.04).
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3.3. Characteristics of cases with and without heart failure
The characteristics of the 101 patients with clinical heart failure compared to those without heart failure are shown in Table 3.
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Although cases of heart failure were significantly more likely to have oedema and chest crepitations these signs were not particularly sensitive or specific (oedema sensitivity 53%, specificity 64%; and chest crepitations sensitivity 54%, specificity 73%). There were also significant differences between cases with and without heart failure in the ECG (rhythm and QRS duration) and chest X-ray (cardio-thoracic ratio, pulmonary congestion). A normal ECG and chest X-ray made a substantial contribution to excluding the diagnosis of clinical heart failure. No case had a cardiothoracic ratio of <0.5. Only 8/101 (8%) of heart failure cases had an ECG in sinus rhythm with an axis between –30° and +120°, a PR interval <200 ms, a ventricular rate between 60 and 99 beats/min and without voltage criteria of LVH. Using these ECG criteria gave a negative predictive value for excluding heart failure of 94% in all cases assessed in the RAHFC. The remaining eight cases had non-specific abnormalities of ST segments and T waves. As expected echocardiographic parameters, such as fractional shortening, were significantly different between the two groups.
3.4. Echocardiographic features of the 101 cases with heart failure
Seventy of 101 cases (78%) had systolic dysfunction as defined by a fractional shortening 
25% or visually abnormal systolic function. Six of 101 cases (6%) had primary valve disease with preserved systolic function. Seventeen of 101 cases (17%) had normal systolic function in the absence of primary valve disease.
3.5. Initiation of therapy
The 78 cases with systolic dysfunction were potentially eligible for ACEI therapy. Twenty-one (27%) of these cases were already on an ACEI (for hypertension) or had a relative or absolute contraindication to the use of this drug class (significant aortic stenosis, creatinine >120 µmol/l, systolic blood pressure <95 mmHg). Of the remaining cases, 56/57 (98%) were commenced on ACEI therapy. The one patient not commenced on an ACEI in the clinic was a 78-year-old male who requested that ACEI therapy be initiated through his GP.
3.6. Cases found not to have heart failure
The diagnoses of the patients who did not have heart failure included those conditions whose clinical presentation overlaps with that of heart failure, i.e. the differential diagnosis of breathlessness, fatigue and fluid retention. In order of decreasing frequency these included cases of obesity (cases with a body mass index >35 kg/m2), chronic air flow limitation, pulmonary fibrosis (often suspected from chest X-ray changes suspicious of congestion which did not clear with diuretics), malignancy (lung, abdominal, disseminated breast) thyroid dysfunction and anaemia. In many cases where heart failure was definitely excluded no evidence of alternative pathology for the presenting symptoms was found.
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4. Discussion |
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TopAbstract1. Introduction2. Methods3. Results4. Discussion5. ConclusionReferences |
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This is the first report of a rapid assessment, hospital based, strategy for diagnosing and managing patients presenting with heart failure for the first time in the community. Approximately three-quarters of all new (incident) cases of heart failure are admitted to hospital as emergencies [3] but the remainder are managed through Emergency Departments without hospital admission, or referred to cardiology outpatients or simply managed in primary care.
As the diagnosis of heart failure has important implications in terms of management and prognosis it is essential to make a correct diagnosis, define aetiology and manage the patient appropriately based on evidence from randomised controlled trials which have shown therapeutic benefit in relation to morbidity and mortality. The RAHFC met these objectives by: (1) providing rapid assessment — an open clinic running every weekday to which patients could be referred without appointment from the Emergency Department or Primary Care; (2) providing a specialist assessment, supported by appropriate cardiac investigations including echocardiography, results of which were then interpreted in a clinical context; and (3) initiating appropriate life saving therapies.
Approximately half of all cases referred were considered to have definite or possible heart failure after their RAHFC assessment. Ultimately, when any additional investigations and trials of therapy were completed, only 26% of all referrals fulfilled the case definition for clinical heart failure. This experience in a specialist outpatient facility emphasises the difficulties in diagnosing this clinical syndrome. So, as reported in previous studies, the low diagnostic accuracy in primary care, where the GP does not usually have the benefit of specialist investigations, is only to be expected. The difficulties are compounded by the GP’s rather infrequent exposure to new cases of heart failure. For a single GP the average number of new patient referrals to the RAHFC was only two cases per year, although in large practices this service was used once per month. Furthermore, in this study some cases were referred to the RAHFC by GPs with an acknowledged low likelihood of having heart failure artificially lowering the final percentage of definite heart failure cases. Without a specialist assessment some of these patients might have been inappropriately managed as heart failure in the community. In those with heart failure treatment with an ACEI was prescribed where indicated.
The RAHFC focused on suspected first presentations of heart failure rather than known heart failure in the belief that the maximum benefit for individual patients was in correctly making a diagnosis, defining aetiology and starting appropriate therapy, rather than in making adjustments to existing treatments. Existing cases are less likely to need the integrated ECG, chest X-ray and echocardiography service, as these investigations would have already been undertaken. This type of heart failure clinic, a rapid access service, is not intended for the long-term management of heart failure. In particular such a specialist service is not an appropriate setting to initiate and up-titrate beta-blocker therapy in cases of heart failure. The RAHFC acts as the first part of a comprehensive district heart failure strategy which addresses the long-term management of this clinical syndrome between hospital and community.
The RAHFC is only one of several strategies for diagnosing and managing heart failure in the community, compared to the usual UK practice based on specialist (consultant), secondary care outpatient assessment of selected cases at the request of the primary care physician (GP). One alternative to this approach is ‘open access’ echocardiography, whereby the primary care physician can directly request an echocardiogram and receive the result without specialist involvement, for the diagnosis of heart failure in the community [16,17]. However, this requires correct interpretation of the echocardiographic information in a clinical context which can only come from the history, examination and other investigations. Although echocardiographic abnormalities were present in all cases of heart failure seen in the RAHFC, 23 cases without clinical heart failure also had abnormalities on their echocardiogram. These included patients with malignancy, which if labelled as heart failure might have delayed the correct diagnosis. Combining some form of specialist cardiologist input with open access echocardiography might overcome some of these difficulties but this strategy then becomes increasingly similar to the assessment provided by the RAHFC. Another strategy is to use readily available investigations in primary care — ECG and chest X-ray — to select cases likely to have heart failure and use this as a basis for referral for secondary care assessment. Symptoms and physical signs are not very sensitive or specific [18] but a normal chest X-ray and ECG make a substantial contribution to excluding the diagnosis of clinical heart failure [19–23]. No case of heart failure had a cardiothoracic ratio less than 0.5 in our study. Other studies have demonstrated a similar correlation between cardiothoracic ratio and left ventricular systolic dysfunction, although not to the same extent [19,22,23]. The use of selected ECG criteria gave a negative predictive value for excluding heart failure of 94% in the cases assessed in RAHFC, and this finding accords with previous studies [19–21]. Biochemical assays of natriuretic peptides have been shown in our previous population study, which used a similar rapid assessment heart failure clinic, to predict the presence of heart failure [24]. The use of these assays, particularly brain natriuretic peptide, could be combined in a diagnostic scheme incorporating ECG and chest X-ray in primary care for selecting patients for open access echocardiography, or referral to cardiology outpatients, or a RAHFC.
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5. Conclusion |
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TopAbstract1. Introduction2. Methods3. Results4. Discussion5. ConclusionReferences |
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As part of an overall strategy for managing cardiovascular disease within the population the RAHFC provides rapid assessment, prompt diagnosis and early introduction of life prolonging therapy for patients presenting with new heart failure in the community. This service represents a benchmark of optimal clinical care against which other strategies for the diagnosis and management of heart failure need to be evaluated.
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Acknowledgements |
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Kevin Fox was supported by a British Heart Foundation Junior Research Fellowship.
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