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European Journal of Heart Failure 2001 3(4):503-507; doi:10.1016/S1388-9842(01)00172-6
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© 2001 European Society of Cardiology

Ambulatory heart failure management in private practice in France

M. Komajdaa,*, J.B. Bouhourb, P. Amouyelc, F. Delahayed, E. Vicaute, I. Crocef, E. Rougemondf, F. Vuittenezg and E. Leuteneggerg

a Service de Cardiologie, Hôpital Pitié Salpétrière 47-83 Bd de l'Hôpital, 75013 Paris, France
b Service de Cardiologie CHU, Bd Jacques Monod St Herblain, 44093 Nantes, Cedex 1, France
c Unité d'épidémiologie, Institut Pasteur 1 rue du Pr. Calmette BP. 245, 59019 Lille, Cedex, France
d Hôpital Cardiovasculaire et Pneumologique BP Lyon Montchat, 69394 Lyon, Cedex 03, France
e Service de Biophysique, Hôpital Fernand Widal 200 rue du Fg Saint Denis, 75010 Paris, France
f Lipha Santé 37 rue Saint Romain, 69379 Lyon, Cedex 08, France
g MediSCAN 15 rue de Turbigo, 75002 Paris, France

* Corresponding author. Tel.: +33-1-42-17-67-21; fax: +33-1-42-17-67-37. E-mail address: michel.komajda{at}psl.ap-hop-paris.fr (M. Komajda).


   Abstract
Top
 Abstract
1. Introduction
 2. Methodology
 3. Results
 4. Discussion
 5. Conclusion
 References
 
Management of ambulatory heart failure was assessed in a group of 600 patients, mean age 73, 64% males, NYHA I: 9%; II: 52%; III: 33%; IV: 6%; followed up by a representative sample of private cardiologists. Fifty-two percent of patients had been previously hospitalised for worsening heart failure with a mean duration of stay of 13.1 days, for those hospitalised in the year preceding the survey (26%). First diagnosis of heart failure had been performed by a cardiologist (57%), a general practitioner (37%) or another category of physician (6%). Seventy percent of patients received three or more different classes of heart failure medications. Diuretics were prescribed to 71%, angiotensin converting enzyme inhibitors to 54% and digitalis to 35% of the population. Beta-blockers were given to only 14% of the patients. In patients aged over 80 years, only 45% received angiotensin converting enzyme inhibitors.

Conclusion: This survey of ambulatory heart failure patients confirms that the disease is predominantly observed in elderly patients, and associated with prolonged and recurrent hospitalisations. The underuse of recommended therapeutic classes including angiotensin converting enzyme inhibitors and beta-blockers deserves further investigation.

Key Words: Ambulatory • Heart failure • Management

Received November 10, 2000; Revised March 14, 2001; Accepted April 26, 2001


   1. Introduction
Top
 Abstract
 1. Introduction
2. Methodology
 3. Results
 4. Discussion
 5. Conclusion
 References
 
Chronic heart failure is a common disease with an estimated prevalence of 0.3–2% in the United States and 1% in France [1–4].

It is the final pathway of all cardiac disorders, mainly coronary artery disease and hypertension.

Chronic heart failure is associated with a high mortality, between 50 and 60% at 5 years (similar to that of common neoplastic diseases), and is a burden for health systems due to the high number of recurrent hospitalisations (150 000 per year in France) which are both prolonged and recurrent. The cost of chronic heart failure absorbs 1–2% of the total health care resources in Western countries [3–9].

The introduction of new drugs has radically changed the pharmacological management of chronic heart failure during the past 20 years, especially in terms of symptom improvement and mortality [10–13]. In the early seventies, the treatment of chronic heart failure was limited to diuretics and digitalis. A better knowledge of the pathophysiology of chronic heart failure, particularly the neurohormonal mechanisms, led to the concept of vasodilatators and the introduction of neuromodulators such as angiotensin converting enzyme inhibitors in the treatment of chronic heart failure.

Following the wide body of evidence from large multicentre trials, angiotensin converting enzyme inhibitors have become the reference drug in chronic heart failure, recommended in international guidelines [14,15] at all stages of the disease, for patients with symptomatic left ventricular systolic dysfunction.

However, several surveys of the treatment of chronic heart failure patients in clinical practice have shown under-prescribing (both in terms of frequency and dosage) of angiotensin converting enzyme inhibitors compared to recent recommendations [16–19]. It is estimated that only 50–60% of patients who should receive angiotensin converting enzyme inhibitors are actually treated with this class.

Moreover, differences in treatment have been observed in Europe particularly in the choice of drugs and their dosage. These differences do not seem to result from a heterogeneity but rather from national traditions, economic circumstances or national guidelines [20].

Our objective was to conduct an observational study of the current medical management of ambulatory chronic heart failure patients treated by private cardiologists in order to assess whether international recommendations are being translated into current practices.

The main objective of this study was to observe the characteristics and the treatment of the chronic heart failure population followed by private cardiologists in France and to determine whether there were differences between sub-groups according to age, aetiology and severity.


   2. Methodology
Top
 Abstract
 1. Introduction
 2. Methodology
3. Results
 4. Discussion
 5. Conclusion
 References
 
A cohort study was carried out using a specific, published and registered methodology (Observatoires Représentatifs des Pathologies, ORP®) [21]. This methodology is based on a combination of the main epidemiological studies rules and some specific tools of clinical studies such as phone monitoring, resolution of queries and quality assurance. In this case, we selected a representative (sex, gender, geography) sample of French private cardiologists. Each selected cardiologist had to include the first 10 consecutive chronic heart failure patients during the period March–October 1999.

A detailed questionnaire included age, sex, New York Heart Association (NYHA) class, duration of heart failure, previous heart failure related hospitalisations and duration of the stay, category of the physician who made the first diagnosis, therapeutic classes prescribed during the survey and any modifications. Diagnosis of heart failure was made at the discretion of the cardiologists according to the European guidelines (Référence: European Heart Journal, 1995).

Quantitative variables were described by the usual measures (mean, standard deviation, median, minimum and maximum). For two-group comparisons, quantitative data were analysed using Anova or Kruskall–Wallis (non-parametric) tests. For multiple comparison (age, NYHA classes), quantitative data were analysed using Anova or Kruskall–Wallis test.

Qualitative variables were described by the usual measures (frequency and percentage) and analysed using Chi-square tests.

In accordance with French legal requirements, the study content was submitted to and accepted by the relevant French Authorities (Conseil National de l'Ordre des Médecins and Commission Nationale de l'Informatique et des Libertés).


   3. Results
Top
 Abstract
 1. Introduction
 2. Methodology
 3. Results
4. Discussion
 5. Conclusion
 References
 
A representative sample of 71 cardiologists participated in this study between March and October 1999. Most of them were men (85%) with a mean age of 46 years.

They recruited 600 outpatients with a main diagnosis of chronic heart failure (64% men and 36% women) with a mean age of 73 years, 34% were <70, 34% 70–79 and 32% were ≥80 years old (Table 1).


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  		Table 1 Age and sex of the patients according to NYHA class

 
The diagnosis of chronic heart failure had been performed prior to inclusion in 91% of cases. The functional status at inclusion was as follows: NYHA class I, 9% of patients; class II, 52%; class III, 33%; and class IV, 6%.

Chronic heart failure was observed predominantly in men under 70 years (81%), conversely it was more frequent in women over 80 years (53%).

Fifty-two percent of the patients had been hospitalised for chronic heart failure before their recruitment into the study and 26% of them in the previous 12 months with a mean duration of hospital stay of 13 days. Both rate and mean duration of hospitalisation increased with the severity of chronic heart failure (Table 2).


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  		Table 2 Characteristics of previous CHF-related hospitalisation according to NYHA class

 
The major cause of chronic heart failure was coronary artery disease or hypertension (59%) (Table 3).


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  		Table 3 Etiology of heart failure according to NYHA class

 
At the time of inclusion, the mean duration of chronic heart failure was 4.2±4.6 years and the average follow-up by the cardiologists was 3.04±3.3 years. The first diagnosis of chronic heart failure was made by a cardiologist in 57% of the patients, by a general practitioner for 37% and by another category of physician in 6% of the cases.

The treatment of chronic heart failure was not influenced by the aetiology. It was characterised by polymedication, 70% of the patients received a poly-therapy, 22% a bi-therapy and only 8% a mono-therapy before inclusion.

The most frequently used therapeutic classes in the whole population were diuretics (71% of the patients), angiotensin converting enzyme inhibitors (54%) and digitalis (35%). Only 14% of the population received beta-blockers (Table 4). Angiotensin converting enzyme inhibitors were prescribed to 75% of patients aged <80 years but to less than 50% of patients aged over 80 years.


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  		Table 4 Major therapeutic classes prescribed before the inclusion

 
At inclusion, one-third of the patients had a modification in their treatment. Modification occurred more frequently in class IV patients (69% vs. 38, 38 and 32%, respectively, in class I, II and III) (Table 5).


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  		Table 5 Major therapeutic classes prescribed after the inclusion and modification of treatment

 

   4. Discussion
Top
 Abstract
 1. Introduction
 2. Methodology
 3. Results
 4. Discussion
5. Conclusion
 References
 
Our survey represents the first observational study of ambulatory heart failure patients followed up by French private cardiologists. In this country, private specialists are responsible for the management of the majority of patients with ambulatory heart failure. Patients are usually referred to private specialists by general practitioners.

Despite the considerable impact of this disease on healthcare costs, few epidemiological data about chronic heart failure are available so far in France [4].

Our results are in agreement with the main results from other epidemiological studies in terms of the age of patients, NYHA class and aetiology. Chronic heart failure patients are mainly elderly, class II and III patients and chronic heart failure is mainly related to coronary artery disease and hypertension [4,6,22].

Our results show that half of the patients were hospitalised within the 4 years following diagnosis, 25% of them were hospitalised during the 12 months prior to their inclusion in the study. Our results are comparable to other studies, showing a rate of re-hospitalisation of 14–34% in the 6 months following the first hospitalisation and a rate of 37% in the following 12 months [23,24]. The duration of the hospitalisation is also similar to that observed (11 days) in two other French studies [4]. In a recent hospital survey, the main duration of the stay was 11 days for men and 14 days for women [22]. Finally, we observed that the rate of hospitalisation as well as the duration of the stay increased with the severity of heart failure.

Cardiac failure is the main cause of hospitalisation in chronic heart failure patients. The major risk factors of cardiac failure are rhythm disorders, infections, poor compliance, angina and drug-related factors (i.e. withdrawal of angiotensin converting enzyme inhibitors, inadequate dosage of diuretics and digitalis toxicity [25,26]). A prospective study carried out among hospitalised patients has shown that more than 50% of the early hospitalisations could have been avoided if better compliance and diet had been more respected and if the follow up of the patients in hospital and in the ambulatory setting had been differently adjusted [27].

More than 90% of the patients were receiving multiple therapy on entering the study. For the recommended therapeutic classes in chronic heart failure, diuretics had been prescribed to 70% of the patients, angiotensin converting enzyme inhibitors to less than 60% and digitalis to 35%. These results confirm several other observational studies that show inappropriate prescribing (both in terms of frequency and dosage) of angiotensin converting enzyme inhibitors, despite the recommendations of the international guidelines for chronic heart failure.

This underuse is all the more remarkable since large multicentre trials such as CONSENSUS I, SOLVD, SAVE, VheFT, AIRE, TRACE have clearly demonstrated that angiotensin converting enzyme inhibitors improve morbi-mortality in mild/moderate or severe chronic heart failure or in post-myocardial infarction with chronic heart failure or left ventricular dysfunction by 30% [12,13,28,29].

Moreover, it has been proven that the new drugs used in chronic heart failure (angiotensin converting enzyme inhibitors and beta-blockers) are cost-effective and limit the cost of this disease in some cases [8,9,30]. Reasons advocated for the underuse of angiotensin converting enzyme inhibitors include the risk of side effects (particularly hypotension and renal failure in the elderly population) and the lack of perception of the potential benefit of angiotensin converting enzyme inhibitors in this disease [16,31].

The use of beta-blockers was observed in only 14% of patients despite the wide body of evidence brought by the US carvedilol program, CIBIS II and MERIT HF trials [11,32,33]. This underuse might be related to the fact that recent scientific evidence has not yet been translated into clinical practice or to the fact that cardiologists are reluctant to start this new class due to the fear of adverse effects.

One of the limits of this survey is the modalities of diagnosis of chronic heart failure that were not recorded and data on cardiac function that were not available. It is, therefore, impossible to sub-categorise patients with or without preserved systolic function and to identify potential differences in the management of these two sub-groups.

However, diagnosis was performed by cardiologists. Therefore, the risk of over or under diagnosis of this condition was limited by the fact that the survey was conducted among specialists. Another limitation is due to the fact that doses of the major drugs used were not analysed. It is therefore, not possible to know whether recommended classes were used at appropriate doses or not.


   5. Conclusion
Top
 Abstract
 1. Introduction
 2. Methodology
 3. Results
 4. Discussion
 5. Conclusion
References
 
This study confirms that chronic heart failure outpatients followed by private cardiologists are mainly in class II and III and mostly men with a mean age of approximately 75 years. This disease causes frequent re-hospitalisations in this elderly population. Diuretics remain the drug of choice independent of the NYHA classification. Angiotensin converting enzyme inhibitors are used in two-thirds of the patients, but in less than 50% of the patients aged over 80 years. Despite the recent approvals in France for this class, the prescribing of beta-blockers remains marginal.

This survey did not include a follow-up of the patients in order to assess the morbi-mortality in this ambulatory population. Very few data are available in clinical practice with this regard. Therefore, additional prospective follow-up studies on the outcome of ambulatory heart failure would be desirable, as well as studies concerning the problem of under use of angiotensin converting enzyme inhibitors and beta-blockers.


   References
Top
 Abstract
 1. Introduction
 2. Methodology
 3. Results
 4. Discussion
 5. Conclusion
 References
 

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