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European Journal of Heart Failure 2003 5(4):549-555; doi:10.1016/S1388-9842(03)00003-5
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© 2003 European Society of Cardiology

Management of chronic heart failure due to systolic left ventricular dysfunction by cardiologist and non-cardiologist physicians

Sinéad P. McKeea, Stephen J. Lesliea, John P. LeMaitrea, David J. Webbb and Martin A. Denvira,*

a Cardiology Unit, Department of Medical Sciences, The University of Edinburgh Western General Hospital, Edinburgh EH4 2XU, UK
b Clinical Pharmacology Unit, Department of Medical Sciences The University of Edinburgh, Western General Hospital, Edinburgh EH4 2XU, UK

* Corresponding author. Tel.: +44-131-537-1733; fax: +44-131-537-1846 E-mail address: martin.denvir{at}ed.ac.uk


   Abstract
Top
 Abstract
1. Introduction
 2. Methods
 3. Results
 4. Discussion
 5. Study limitations
 6. Conclusion
 References
 
There are now a number of guidelines outlining the diagnosis and management of patients with chronic heart failure (CHF). The extent to which these guidelines are used and the effects on patient outcomes are not well known. The aim of this study was to examine the implementation of a heart failure guideline among cardiologist and non-cardiologist physicians in a university hospital setting. Case record data were examined from 400 patients with a primary diagnosis of CHF. Management of these patients was assessed using a systolic heart failure guideline (Scottish Intercollegiate Guideline Network, number 35) as a benchmark. Hospital admission data were examined contemporaneously over a 17-month period to assess associations between adherence to drug therapies and number of admissions. Overall, there was poor adherence to the guideline, with relatively high use of angiotensin-converting enzyme (ACE) inhibitors/angiotensin II receptor blockers (ARBs) (80%), low use of beta-blockers (32%) and digoxin (36%), and very low use of spironolactone (13%). Cardiologists used more beta-blockers (37 vs. 21%, P=0.003) and digoxin in sinus rhythm (18 vs. 5%, P<0.001) than non-cardiologists. Hospital admission rate was individually associated with increasing age, NYHA status, beta-blocker, diuretic and spironolactone prescription (all P<0.001). At multivariable analysis, only age, NYHA status and increased diuretic prescription were associated with more frequent admission (P<0.001, R2=0.15). Despite carefully designed guidelines, the implementation of evidence-based therapies for CHF remains inadequate, even in a university hospital environment. This may reflect a lack of organisational developments to facilitate the increasingly complex management of patients with CHF.

Key Words: Scottish Intercollegiate Guideline Network (SIGN) • Left ventricular systolic dysfunction • Chronic heart failure

Received April 5, 2002; Revised June 26, 2002; Accepted October 21, 2002


   1. Introduction
Top
 Abstract
 1. Introduction
2. Methods
 3. Results
 4. Discussion
 5. Study limitations
 6. Conclusion
 References
 
Chronic heart failure (CHF) remains a major cause of morbidity and mortality in the United Kingdom (UK) and is likely to become an even greater problem as the population ages and new therapies improve survival after acute myocardial infarction [1]. There are a number of landmark randomised clinical trials using digoxin [2], angiotensin-converting enzyme inhibitors (ACE-I) [3,4], beta-blockers [5–8] and spironolactone [9] confirming mortality and morbidity benefits for patients with CHF. Additional benefits have been described for other interventions, such as influenza vaccination [10], exercise training [11,12], dietary advice and educational programs [13–15]. The results of these trials have been critically reviewed, simplified and summarised by panels of experts into guidelines outlining the diagnosis and management of CHF [16–20]. These guidelines have been hailed as a major step in disseminating information and evidence from randomised trials into clinical practice. It might be expected that guidelines would improve the management of heart failure to a greater extent among non-cardiologists, since cardiologists would be expected to maintain a good working knowledge of recent evidence. Guidelines would therefore change their practice to a lesser extent. The successful implementation of heart failure guidelines has not been widely assessed between cardiologist and non-cardiologist physician groups.

The aim of this study was to compare cardiologist and non-cardiologist physicians’ implementation of the Scottish Intercollegiate Guideline Network (SIGN) guideline on systolic heart failure (number 35) [20] in a secondary care environment. This guideline was published in February 1999 and circulated to all physicians throughout Scotland. It is also available online at www.sign.org.uk. Based on patient symptoms, the guideline recommends treatment for heart failure due to left ventricular systolic impairment with ACE inhibitors, beta-blockers, spironolactone and digoxin. The guideline also recommends a once-only pneumoccal immunisation, annual influenza vaccination, diuretics for fluid retention, aspirin and lipid-lowering therapy for patients with ischaemic aetiology.


   2. Methods
Top
 Abstract
 1. Introduction
 2. Methods
3. Results
 4. Discussion
 5. Study limitations
 6. Conclusion
 References
 
A total of 400 CHF patients were identified from various sources, including an echocardiography database, cardiology and general medical wards, and cardiology outpatient clinics in our hospital over a 17-month period between August 1999 and January 2001. The number of admissions with a primary diagnosis of heart failure was recorded over the same 17-month period. Admission data were obtained using case notes and a computerised hospital information system.

Patients were included if they had either a clinical diagnosis of CHF documented in their case notes or evidence of moderate or severe left ventricular (LV) systolic impairment on echocardiography or left ventricular angiography. The majority of these were ‘eyeball’ assessments of LV function recorded during routine clinical assessment. In our institute, moderate or severe systolic impairment is acknowledged as representing an ejection fraction of less than 40%. Patients with mild systolic impairment documented in the case record or in echocardiography reports were not included, since these were presumed to represent patients with relatively preserved ejection fractions. Data were recorded on aetiology, co-morbid conditions, drugs, investigations, New York Heart Association (NYHA) classification and the speciality of the secondary care physician managing the patient. NYHA classification was recorded from the case record based on symptoms at the last outpatient clinic review, or at the time of hospital discharge. Patients with symptoms of heart failure and preserved LV function were not included in the analysis, since the SIGN guidelines do not apply to this patient group. Permission for the study was obtained from the local ethical committee.

2.1. Statistics
Data analysis was performed using SPSS for Windows, v. 11. Continuous variables were compared between groups using a t-test for normally distributed data or the Mann–Whitney U-test for data with unequal distribution. Grouped variables were compared using Pearson chi-square ({chi}2) test, with Fisher's exact test performed where appropriate. Multivariable analyses were performed using a general linear model. Data are presented as mean with 95% confidence intervals unless otherwise stated. A P value of <0.05 was considered statistically significant.


   3. Results
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
4. Discussion
 5. Study limitations
 6. Conclusion
 References
 
3.1. CHF patient data
The mean age of all patients was 71 years (95% CI 69.8–72.1). Coronary artery disease was recorded as a diagnosis in 70% and hypertension in 33% of all patients (Table 1). Idiopathic dilated cardiomyopathy was recorded as a diagnosis in only 6% of patients (Table 1) and atrial fibrillation in 38% (Table 2). In the group as a whole, ACE-I/angiotensin II receptor blockers (ARBs) were used in the majority of patients without a documented contraindication (80%; Table 3), with beta-blockers used in only one-third (32%) and spironolactone infrequently (13%). Reasons for not using ACE-I, beta-blockers and spironolactone were rarely recorded in patient case records. Common reasons for not using beta-blockers were not well documented, but included asthma and chronic pulmonary disease (14%) and peripheral vascular disease (6%). Digoxin was used in 36% of patients, but was used infrequently for patients in sinus rhythm (13%). Influenza vaccination status was not recorded in the case record of any of the 400 patients.


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  		Table 1 Patient characteristics

 


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  		Table 2 Co-morbidities: results of chronic heart failure survey

 


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  		Table 3 Drug therapies and contraindications recorded for whole study group, and therapies for patients without documented contraindications to ACE-I/ARB and beta-blockers

 
Spironolactone was used more often for patients with NYHA class III–IV CHF than class I–II (22 vs. 7%, P<0.001). Digoxin was equally likely to be used in NYHA I–II and III–IV patients (35 vs. 38%, P=0.55). Beta-blockers were more likely to be prescribed for patients in NYHA I–II than class III–IV (33 vs. 18%, P<0.001).

3.2. Cardiologists vs. non-cardiologists
Cardiologists managed 67% (n=268) of the patient group. The non-cardiologist group (n=132, 33%) comprised physicians from several specialities, including general medicine (n=64, 16%), care of the elderly (n=29, 7%), diabetes and endocrinology (n=29, 7%), respiratory medicine (n=7, 2%) and others (n=3, 1%). Patients managed by non-cardiologists were older (77 [95% CI 75.4–78.8] vs. 68 [66.6–69.3] years, P<0.001) and more likely to be female (45 vs. 30%, P=0.002), have greater functional limitation (NYHA III–IV, 48 vs. 34%, P=0.010) and have more co-morbid conditions (hypercholesterolaemia 17 vs. 38%, P<0.001, chronic obstructive airways disease 19 vs. 7%, P<0.001) than those managed by cardiologists. Cardiologists were more likely to use beta-blockers (37 vs. 21%, P=0.003) and digoxin in sinus rhythm (18 vs. 5%, P<0.001). Patients managed by cardiologists were also more likely to be on statin therapy (36 vs. 23%, P=0.010) despite a similar proportion with ischaemic heart disease (72 vs. 64%, P=0.12). Patients managed by cardiologists were less likely to be taking loop diuretics (70 vs. 83%, P=0.004) but there was no difference in the use of spironolactone between cardiologists and non-cardiologists (13 vs. 14%, P=0.636). Warfarin was used more commonly by cardiologists (26 vs. 17%, P=0.042) despite a lower proportion of patients in atrial fibrillation (34 vs. 44%, P=0.06). Aspirin was used in a similar proportion of patients (66 vs. 65%, P=0.918).

3.3. Hospital admission data
Compared with patients in NYHA class I–II during the study period, NYHA class III–IV patients were more likely to have two or more admissions (29 vs. 11%, odds ratio 1.9, 95% CI 1.47–2.36, P<0.001) and less likely to have no admissions (19 vs. 49%, odds ratio 0.4, 95% CI 0.28–0.56, P<0.001). In addition, patients older than 70 years were more likely to be admitted with heart failure than patients aged less than 50 (70 vs. 50%, P=0.016). Beta-blockers were prescribed less frequently to patients with one hospital admission with heart failure compared with those not admitted at all (26 vs. 36%, P=0.001). Beta-blockers were also less frequently prescribed to patients who had had multiple admissions, i.e. two or more, compared with patients with only one admission (12 vs. 26%, P=0.001, Fig. 1). Digoxin was prescribed more frequently to patients who had been admitted on two or more occasions compared with those patients admitted once (50 vs. 35%, P=0.02). Diuretic (loop or thiazide) was prescribed more frequently in patients admitted once compared to those patients never admitted (85 vs. 63%, P<0.001) and more frequently for those patients with two or more admissions compared with patients with one admission (90 vs. 85%, P<0.001). Spironolactone was also prescribed more frequently in patients admitted once compared with those not admitted (18 vs. 5%, P<0.001) and in patients with two or more admissions compared with those admitted only once (24 vs. 16%, P<0.001). Rates of prescription of ACE-I, ARB or statins did not vary between groups admitted or not admitted to hospital. Patients managed by cardiologists had fewer admissions compared to patients managed by non-cardiologist physicians (0.82 [95% CI 0.7–0.93] vs. 1.02 [0.89–1.14] admissions, P=0.037).


Figure 1
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  		Fig. 1 Frequency of drug prescription in admission groups ACE-I/ARB, angiotensin-converting enzyme/angiotensin II receptor blocker; BB, beta-blocker; spiro, spironolactone.

 
Univariate linear regression analysis identified individual associations between frequency of hospital admission and increasing age (P<0.001, R2=0.04), NYHA class (P<0.001, R2=0.10), number of co-morbid medical conditions (P=0.05, R2=0.01), loop/thiazide diuretic prescription (P<0.001, R2=0.06), spironolactone prescription (P<0.001, R2=0.04), digoxin prescription (P=0.007, R2=0.02) and decreased beta-blocker prescription (P<0.001, R2=0.04). With multivariate analysis, only age, NYHA status and increased loop/thiazide prescription remained independently associated with increased frequency of hospital admission (P<0.001, R2=0.16).


   4. Discussion
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
5. Study limitations
 6. Conclusion
 References
 
This observational study has sought to examine the relationship between guideline implementation and hospital admissions in an unselected population of CHF patients. There are no studies demonstrating that heart failure guidelines directly reduce mortality or hospital admissions, but it is generally accepted that widespread implementation should achieve benefits similar to those observed in randomised clinical trials. It is clear from the results of our survey that the SIGN guideline is not well implemented in this secondary care environment by either cardiologist or non-cardiologist physicians. Comparing cardiologists with non-cardiologist physicians, implementation, as reflected by use of appropriate drug therapies, was significantly different only for beta-blockers and digoxin, with similar under-use of other evidence-based therapies. However, although the overall use of recommended CHF therapies was disappointingly low, it was similar to that observed in other European countries, such as Italy [21]. This would suggest that our findings observed in a secondary care university institute in the National Health Service in the UK, may be a reasonable reflection of practice in other centres in Europe.

The reasons for inadequate implementation are probably multifactorial. Some of the variations in use of drug therapies may be explained by different patient populations; for example, cardiology patients were younger and may therefore have had a higher tolerance of multiple therapies. Variations between physician groups may also reflect individual clinician interpretation and extrapolation of trial evidence, which is limited in the elderly and female population for a number of key therapies. Similar attitudes may also explain some of the reluctance to prescribe digoxin and lipid-lowering therapy. Despite substantial evidence supporting the use of ACE inhibitors, prescription of this drug class is still less than that recently observed in patients enrolled in a large randomised trial of the angiotensin II receptor antagonist valsartan [22]. In our study, 20% of patients had no documented reason for not receiving this drug.

The use of beta-blockers was low in both groups, despite good trial evidence of their benefits on mortality, morbidity and hospital admission rates. This suggests that there is ongoing reluctance and difficulties in using beta-blockers in CHF patients. One reason may relate to the limited availability of an initiation and up-titration service within this institution. Furthermore, we found that beta-blockers were less likely to be used in patients frequently admitted to hospital and with more severe heart failure symptoms. Recently, trials have suggested that these are the patients most likely to gain the greatest benefit [8].

Spironolactone was used in a minority of patients, despite a large, randomised placebo-controlled trial confirming a 27% reduction in death or progressive heart failure in patients with NYHA III–IV heart failure [9]. In addition, it was used in only 26% of patients eligible by NYHA criteria for the randomised trial and in 7% of patients who would have been excluded from the trial on this criterion. These data support the need for detailed and careful wording of heart failure guidelines embracing the inclusion criteria from trials. Our data also suggest that many physicians remain uncomfortable about the risk of hyperkalaemia when combining spironolactone with ACE inhibitors. This has also been confirmed in other small studies [23] and may reflect the limited support within the community to regularly monitor blood chemistry in these patients.

Cardiologists were significantly more likely to use digoxin in both sinus rhythm and atrial fibrillation. Overall, digoxin was used in only 38% of NYHA III–IV and 35% of NYHA I–II patients, despite a potential reduction of 30% and 22%, respectively, in the combined endpoint of death or hospitalisation in these groups of patients [2]. The use of digoxin was not associated with significant differences in admission rates in our patient group at multivariable regression analysis. The reluctance to use digoxin remains unexplained, but appears to reflect a degree of scepticism of its effectiveness among physicians and cardiologists in the UK.

Influenza immunisation was not well recorded within case notes. The evidence supporting this treatment comes predominantly from a large observational study in the United States, which demonstrated, during an influenza epidemic, a significant reduction in hospital admissions of CHF patients in those receiving immunisation compared with those who did not [10]. Influenza epidemics can cause major problems with bed occupancy in the winter months. As such, it is extremely important that this evidence is effectively used by ensuring CHF patients have had immunisation and that this is documented in the case record. This is an area where communication between primary and secondary care is crucial.

Admission was associated with increasing age and severity of heart failure. These patients should be targeted for careful management and implementation of CHF guidelines. Cardiologists tended to manage younger patients than did non-cardiologists. This age difference may partly explain differences in use of effective treatments, such as beta-blockers and spironolactone, which may be tolerated better and up-titrated more easily in younger patients. The main focus for ensuring that these drugs are more widely used is by facilitating the process of initiation, up-titration and careful monitoring of treatment in the community by a multidisciplinary team.


   5. Study limitations
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
 5. Study limitations
6. Conclusion
 References
 
This was a purely observational study and as such has significant limitations. Data were collected retrospectively and there may have been inadequacies in the information recorded in case records. Patients with CHF may have been missed; patients may have been inappropriately recorded as having moderate or severe systolic impairment. No formal check was made of the case record diagnosis of CHF. In addition, the NYHA status was recorded only once from the case record and no account was made of possible changes during the course of the observation period. These factors may have significantly influenced data interpretation.


   6. Conclusion
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
 5. Study limitations
 6. Conclusion
References
 
This study has demonstrated that, despite well-written and widely distributed guidelines, the use of evidence-based therapies for patients with heart failure due to LV systolic impairment remains inadequate, even in a university secondary care centre. There are significant differences in the use of some drug treatments by cardiologist and non-cardiologist physicians, which may be accounted for by differences in age, co-morbid conditions and severity of heart failure in their respective patient groups. There is a clear need to develop strategies that will improve the uptake of evidence-based guidelines by all physicians.


   References
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
 5. Study limitations
 6. Conclusion
 References
 

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