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Last update: 21/10/99.

Author: Francisco Machado

Some facts about heart failure

• Chronic Heart Failure affects up to 2% of The UK Population and 10% of the elderly

• 60% annual mortality in severe cases
• 50% 5 year survival in mild cases
• significant morbidity
• 120,000 hospital admissions costing an estimated £360 million to the NHS
• accounts for an estimated 1.68 million GP consultations per year!!

Heart Failure in General Practice

Mair et al 1996 BJGP Feb 1996.

Looked at the prevalence, aetiology and management of heart failure in two practices with a combined population of 17 400.

Findings were:

Prevalence of 1.5% in all pts and 8% in patients over 65

Principal aetiological considered responsible was:

• coronary heart disease 45%
• hypertension 18%
• valve disease 9%
• cor pulmonale 7%
• cardiomyopathy 2%
• unknown 17%

Investigations performed

• Renal function checked in the last year 59%
• ECG 80%
• CXR 89%
• Echo 30%
• Prescribed ACEI 33% ( most at doses lower than in the trials)

Making the diagnosis.

Davie AP et al. Assessing diagnosis in heart failure: which features are any use? Q J Med 1997; 90: 335-339.

259 patients referred by their GPs to OPD for assessment of LVSD by Echo

Patients were all seen by one Investigator and a structured history and examination was performed.

All patients then had an ECHO by another investigator.

Only 16% of patients with suspected HF were found to have LVSD

Findings:

• Absence of dyspnoea on exertion virtually ruled out the diagnosis, LR - 0.03
• Displaced apex (LR +16.5) and S3 Gallop (LR +24) were strong indicators of heart failure.
• Raised JVP (LR +8.5)
• The presence of A raised JVP, displaced apex and S3 gallop in a patient with dyspnoea is virtually diagnostic of HF

Investigations

What investigations will help?

• Bloods FBC, TFT, U/Es important but in themselves will not help with the diagnosis

• ECG. There are no diagnostic features but ECG will give clues to cause. But the ECG is very unlikely to be normal in a patient with significant HF. If normal need to review the diagnosis
• CXR. Is unlikely to be normal in a patient with HF>
• ECHO. All current guidelines recommend that an ECHO is performed on all patients with suspected HF.

Management

Digoxin

In CCF and AF Digoxin is used to control vent rate.

What about in sinus rhythm?

The digitalis Intervention Group. NEJM 1997; 336: 525-533. 6800 pts with LVEF < 0.45 in SR, enrolled in a double blind controlled trial of digoxin vs placebo. There was no effect in mortality but there was a reduction in hospital admissions and benefits were greater in patients with severe heart failure. Findings were irrespective of other medication.

Angiotensin Converting Enzyme Inhibitors ACEI

Have been shown to:

• improve symptoms

• reduce mortality
• reduce hospital admissions

The North of England evidence-based development project: guideline for ACEIs in primary care management of adults with symptomatic heart failure, advised the following: (1)

• All patients with symptomatic heart failure and evidence of impaired left ventricular function should be treated with an ACEI as they have been shown to reduce mortality in symptomatic patients who have who have a ejection systolic fraction of less than <35%
• Patients with recent myocardial infarction and evidence of LV dysfunction should be treated with an ACEI
• ACEI have been shown to improve symptoms and exercise tolerance in patients with symptomatic heart failure and reduced systolic function
• ACEI treatment is cost effective due to reduced admission of patients with heart failure when on ACEI

The paper also made the following recommendations

• As there is no good evidence of clinically important differences in the effectiveness of available ACEIs, patients should be treated with the cheapest drug that they can effectively use

Beta Blockers

An editorial in the BMJ (2) discussed the evidence for the use of beta-blockers in heart failure.

Summary of findings:

• CIBIS-II study (3) comparing bisoprolol and placebo reported a highly significant reduction in all case mortality
• There are now 25 trials that have randomised patients with heart failure to beta-blocker control and placebo and pooled results have demonstrated a reduced odds ratio of death by 36%, this compares with 24% for ACEI !
• Most of the patients in the ß blocker trials were already on ACEI therefore their effects are in addition to ACEIs.

Some reservations include:

• under representation of patients over 75 years of age in trials
• carvedilol only ß-blocker currently licensed for use in heart failure
• ß-blockers should not be used in acute situations unlike using diuretics and ACEIs

Using ß-blockers in heart failure should include:

• make sure diagnosis is correct
• should be used to prevent complications in patients with symptoms in mild heart failure
• dose requires slow titration with careful observation

Spironolactone

ACEIs block the production of aldosterone but this may not be complete and the recent Randomised Aldactone Evaluation Study (RALES) (4) demonstrated a relative risk reduction in mortality of 30% when 25mg of spironolactone was added to standard therapy in patients with severe type III and IV heart failure.

There were also:

• 35% fewer admissions for worsening heart failure
• an improvement in symptoms

Spironlactone is able to block all the effects of aldosterone.

Patients on ACEI and low dose spironolactone need careful monitoring of their potassium levels but there were few problems in the trial.

Useful references:

The Practitioner November 1997

BJGP October 1995 517-519

(1)    Eccles M et al. North of England evidence based development project: guideline for ACEIs in primary care management          of adults with symptomatic heart failure BMJ 1998; 316: 1369-76

(2)     Cleland JGF, et al The evidence for ß blockers in heart failure. BMJ 1999; 318: 824-5

(3)    The CIBIS-II Investigators and Committees. The cardiac insufficiency bisoprolol study II (CIBIS-II): a randomised trial.

        Lancet 1999; 353: 9-13

(4)    RALES study preview can be seen here.

Last up date 21/10/99 Francisco Machado