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European Journal of Heart Failure 2003 5(3):345-348; doi:10.1016/S1388-9842(03)00049-7
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© 2003 European Society of Cardiology

Diagnosis and management of heart failure: a questionnaire among general practitioners and cardiologists

Frans H. Rutten*, Diederick E. Grobbee and Arno W. Hoes

Utrecht Heart Failure Organisation (UHFO), Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht Utrecht, The Netherlands

* Corresponding author. Utrecht Heart Failure Organisation (UHFO), Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, P.O. Box 85060, Stratenum 6.101, 3508 AB Utrecht, The Netherlands. Tel.: +31-30-2538542; fax: +31-30-2539028; www.juliuscenter.nl. E-mail address: f.h.rutten{at}med.uu.nl

Received December 12, 2002; Accepted March 21, 2003


   1. Background
Top
 1. Background
2. Aims
 3. Methods
 4. Results
 5. Conclusion
 References
 
Heart failure has gradually become one of the most prevalent cardiovascular disorders in Western Societies, notably in the elderly [1,2]. Notwithstanding the public health importance of heart failure, current management of heart failure in clinical practice seems far from optimal [3–6].

Data on perceptions [7–9], diagnosis and management of patients with heart failure, in every day care are, however, scarce [10,11]. In particular, studies comparing primary and secondary care are virtually non-existent [10].


   2. Aims
Top
 1. Background
 2. Aims
3. Methods
 4. Results
 5. Conclusion
 References
 
To compare perceptions about heart failure diagnosis and management, between cardiologists and general practitioners (GPs) in the Netherlands.


   3. Methods
Top
 1. Background
 2. Aims
 3. Methods
4. Results
 5. Conclusion
 References
 
In the year 2000, 150 GPs in the Netherlands were sent a questionnaire. The practices were located in the vicinity of Utrecht, were both urban and rural, and included single-handed and group practices. In total, 99 (62%) of the GPs participated. Forty-five (45%) of the participating GPs also took part in our study using patient files (see paper by Rutten et al. in this issue). All invited GPs routinely register their patient contacts in ELIAS (SMS Cendata Nieuwegein); a software package suitable for electronic registration of medical information. In addition, 58 cardiologists were sent a questionnaire. Cardiologists were selected at random from one academic, three middle size, and five smaller hospitals in the Netherlands. Thirty-six (62%) cardiologists participated. Twenty-four (67%) of the participating cardiologists also took part in our study on patient files (see paper by Rutten et al. in this issue).

The questionnaire contained 21 questions, with dichotomous response options, concerning aspects of the diagnosis and management of heart failure.

The study was conducted as part of the Utrecht heart failure organisation.

Approval of the study was obtained from the Ethics Committee of the University Medical Center Utrecht, the Netherlands.

3.1. Data analysis
Differences in proportions were assessed by means of {chi}2 tests. All analyses were undertaken using SPSS for WINDOWS version 9.0 (SPSS, Chicago, Illinois).


   4. Results
Top
 1. Background
 2. Aims
 3. Methods
 4. Results
5. Conclusion
 References
 
Prior myocardial infarction (69 vs. 83%) and hypertension (59 vs. 72%) are seen as important features in history by both GPs and cardiologists (Table 1). Of symptoms, dyspnoea (81 vs. 97%), and peripheral oedema (77 vs. 72%) are qualified as most important by both. Pulmonary crepitations (93 vs. 92%), peripheral oedema (90 vs. 81%), and the presence of an elevated jugular venous pressure (69 vs. 67%) are considered important signs (Table 1). In addition, cardiologists pay relatively more attention to heart murmurs (16 vs. 36%) and a third heart sound (12 vs. 44%) than GPs.


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  		Table 1 Items from history taking, and symptoms and signs considered most important in suspected heart failure by GPs and cardiologists

 
Chest radiography (98 vs. 100%) and electrocardiography (85 vs. 94%) are used most often as additional diagnostic investigations, in both primary and secondary care. As a subsequent diagnostic tool, GPs prefer a change in symptoms following test treatment with diuretics (97 vs. 49%), while cardiologists prefer (Doppler) echocardiography (62 vs. 100%) and coronary angiography (15 vs. 81%) (Table 2). Currently, neuropeptides (such as atrial natriuretic peptide (ANP) or brain natriuretic peptide (BNP)) do not play an important role as a diagnostic tool in heart failure (Table 2).


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  		Table 2 Investigations considered most important by GPs and cardiologists in suspected heart failure, in addition to history taking, and signs and symptoms

 
As first choice medical treatment GPs prescribe diuretics (63 vs. 29%, P=0.001), while cardiologists primarily prefer a combination of ACE inhibitor and diuretics (32 vs. 63%, P=0.001). All cardiologists (100%), but only 35% of the GPs ever prescribe β-blockers for heart failure. In case of persisting symptoms in patients being treated with diuretics and ACE inhibitors, GPs add spironolactone and digoxin, while cardiologists also use β-blockers or angiotensin II antagonists as additional therapy (Table 3).


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  		Table 3 Treatment considered most important by GPs and cardiologists in patients with heart failure, who still report complaints when treated with diuretics and ACE inhibitor

 
There were no significant differences between GPs who participated in the patient files study (see paper by Rutten et al. in this issue) and the other GPs. Also, between cardiologists who participated in the patient files study and those who did not, answers to the questions in the questionnaire did not differ significantly.


   5. Conclusion
Top
 1. Background
 2. Aims
 3. Methods
 4. Results
 5. Conclusion
References
 
Differences in diagnosis and management of heart failure between GPs and cardiologists primarily concern preferences in additional investigations and pharmacological interventions. GPs tend to diagnose heart failure on clinical grounds, not making use of echocardiography facilities. This tendency has also been observed in other studies [7,9,11]. Limited access to echocardiography for primary care patients is probably an explanation for this discrepancy.

At the moment neuropeptides, such as ANP and BNP do not play an important role in either primary or secondary care in the Netherlands, although studies have shown their potential usefulness as a diagnostic tool [12–15].

Our study shows that GPs often rely on a ‘positive’ reaction following initiation of diuretics as a diagnostic tool in suspected heart failure. Although several guidelines, including the European Society of Cardiology mention improvement in symptomatology following appropriate therapy as an important diagnostic sign [16], its diagnostic value is unknown and should be assessed.

In contrast to cardiologists, most GPs consider monotherapy with diuretics an important option in heart failure treatment. In addition, GPs are reluctant to prescribe β-blocking agents. Differences between primary and secondary care populations could play a role in these preferences of the GPs, because on average, primary care patients are 10–15 years older and more often female [4,5,7,17,18].


   Acknowledgements
 
We thank the participating general practitioners, internists and cardiologists. In addition, we thank Diana Balk, Renate Siebes and Peter Zuithoff for administrative assistance and statistical help, and Geert van der Heijden for critically reading the manuscript. Financial support for this study was obtained from the Dutch Heart Foundation, grant number 48006.


   References
Top
 1. Background
 2. Aims
 3. Methods
 4. Results
 5. Conclusion
 References
 

  1. Cowie M.R., Mosterd A., Wood D.A., et al. The epidemiology of heart failure. Eur Heart J (1997) 18:208–225.[Free Full Text]
  2. Senni M., Tribouilloy C.M., Rodeheffer R.J., et al. Congestive heart failure in the community: trends in incidence and survival in a 10-year period. Arch Intern Med (1999) 159:29–34.[Abstract/Free Full Text]
  3. Clarke K.W., Gray D., Hampton J.R. Evidence of inadequate investigation and treatment of patients with heart failure. Br Heart J (1994) 71:584–587.[Abstract/Free Full Text]
  4. Cleland J.G., Swedberg K., Cohen-Solal A., et al. The Euro heart failure survey of the EUROHEART survey programme. A survey on the quality of care among patients with heart failure in Europe. The study group on diagnosis of the working group on heart failure of the European society of cardiology. The medicines evaluation group centre for health economics university of York. Eur J Heart Fail (2000) 2:123–132.[Abstract/Free Full Text]
  5. Hood S., Taylor S., Roeves A., et al. Are there age and sex differences in the investigation and treatment of heart failure? A population-based study. Br J Gen Pract (2000) 50:559–563.[Web of Science][Medline]
  6. Mair F.S., Crowley T.S., Bundred P.E. Prevalence, aetiology and management of heart failure in general practice. Br J Gen Pract (1996) 46:77–79.[Web of Science][Medline]
  7. Hobbs F.D.R., Jones M.I., Allan T.F., Wilson S., Tobias R. European survey of primary care physician perceptions on heart failure diagnosis and management (Euro-HF). Eur Heart J (2000) 21:1877–1887.[Abstract/Free Full Text]
  8. Hobbs F.D.R. Management of heart failure: evidence versus practice. Does current prescribing provide optimal treatment for heart failure patients? Br J Gen Pract (2000) 50:735–742.[Web of Science][Medline]
  9. Edep M.E., Shah N.B., Tateo I.M., Massie B.M. Differences between primary care physicians and cardiologists in management of congestive heart failure: relation to practice guidelines. J Am Coll Cardiol (1997) 30:518–526.[Abstract]
  10. The study group on diagnosis of the working group on heart failure of the European Society of Cardiology. Increasing awareness and improving the management of heart failure in Europe: the improvement of HF initiative. Eur J Heart Fail 1999;1:139–44.
  11. Cleland J., Swedberg K., Follath F., Cohen-Solal A., Hobbs R. The Improvement survey of perceptions and practice: diagnosis of heart failure in Europe. Eur J Heart Fail (2001) 3(Suppl. 1):S2. Abstract.
  12. Smith H., Pickering R.M., Struthers A., Simpson I., Mant D. Biochemical diagnosis of ventricular dysfunction in elderly patients in general practice: observational study. BMJ (2000) 320:906–908.[Abstract/Free Full Text]
  13. Cowie M.R., Struthers A.D., Wood D.A., et al. Value of natriuretic peptides in assessment of patients with possible new heart failure in primary care. Lancet (1997) 350:1349–1353.[CrossRef][Web of Science][Medline]
  14. Landray M.J., Lehman R., Arnold I. Measuring brain natriuretic peptide in suspected left ventricular systolic dysfunction in general practice: cross-sectional study. BMJ (2000) 320:985–986.[Free Full Text]
  15. McClure S.J., Caruana L., Davie A.P., Goldthorp S., McMurray J.J.V. Cohort study of plasma natriuretic peptides for identifying left ventricular systolic dysfunction in primary care. BMJ (2000) 317:316–319.
  16. Remme W.J., Swedberg K. Guidelines for the diagnosis and treatment of chronic heart failure. Eur Heart J (2001) 22:1527–1560.[Free Full Text]
  17. Rutten F.H., Hoes A.W. Management of heart failure: differences between general practitioners and cardiologists. Eur J Heart Fail (2001) 3(Suppl. 1):S1. Abstract.[Free Full Text]
  18. Mujais S.K., Nora N.A., Levin M.L. Principles and clinical uses of diuretic therapy. Prog Cardiovasc Dis (1992) 35:221–245.[CrossRef][Web of Science][Medline]

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