ArticlesManagement of heart failure in primary care (the IMPROVEMENT of Heart Failure Programme): an international survey
Introduction
Findings of epidemiological studies suggest that there are 50 million people with suspected or confirmed heart failure in Europe and neighbouring countries.1, 2, 3, 4, 5 The diagnostic and treatment burden of this disorder is large. Heart failure is also malignant and costly, both in terms of morbidity and resources.6, 7 Importantly, treatment for heart failure is highly effective.8
The Working Group on Heart Failure of the European Society of Cardiology (ESC) published guidelines for diagnosis in 1995,4 updated in 2001,5 that recommended minimum requirements for the investigation of suspected heart failure. These guidelines drew attention to the inadequacy of diagnosis by clinical means alone, and the working group suggested that objective assessment of cardiac dysfunction, usually by echocardiography, should be done. In treatment guidelines from 1997, updated in 2001,5 the ESC recommended widespread use of both angiotensin-converting enzyme (ACE) inhibitors and β blockers to improve symptoms and prognosis.9 Despite these recommendations, results from recent studies suggest that many patients with heart failure are not receiving these agents.10, 11 Additionally, if ACE inhibitors and β blockers are prescribed, the dose is often below the range that has been shown to confer a mortality benefit.10, 12
In Europe, patients with heart failure are managed mostly in the community by primary-care physicians. Such physicians have a key role in early identification, adequate assessment, and optimum treatment of heart failure. However, few studies provide information about doctors' knowledge of the management of heart failure, and how this knowledge translates into clinical practice. The aim was to address these issues by undertaking a large international survey of clinical practice in primary care.
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Methods
The rationale for, and design of, the survey have been published in detail elsewhere.13 The IMPROVEMENT (Improvement programme in evaluation and management) of heart failure initiative was developed by an international advisory board of primary-care and secondary-care physicians to increase awareness of heart failure among health-care workers in Europe, and to improve management. In the first phase, the advisory board developed two sets of questions that were based on the guidelines for the
Results
1363 primary-care physicians agreed to participate in the study. Table 1 shows that participation rates ranged from 22% in Sweden to 100% in Russia, that most participating physicians were aged between 41 and 50 years, and that the proportion of female doctors varied greatly between countries.
Data were obtained for 11 062 patients. 8361 (76%) patients had symptoms of heart failure and were reported to have breathlessness, fatigue, and ankle swelling (table 2). Between a third and a half of
Discussion
This study provides an international comparison of primary-care physicians' knowledge and attitudes to the management of patients with heart failure18 and characteristics and treatment of those with heart failure in primary care. Physicians seemed well informed about appropriate investigation of heart failure, with the possible exception of differentiation of systolic from diastolic heart failure. They also seemed well informed about the symptomatic and prognostic benefits of ACE inhibitors
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See end for a full list of committee members and national and regional co-ordinators.
See http://image.thelancet.com/extras/01artl0209webappendix.pdf for full list of investigators