Heart failure: optimizing early detection and subsequent drug treatment in older people

Abstract

Heart failure (HF) is a progressive syndrome mainly and often encountered in older people, and has been called ‘the cardiovascular epidemic of the 21st century’. With extrapolation of the results of our literature review about the prevalence of HF in the older population at large, we even think the prevalence is underestimated.

The majority of patients with HF is diagnosed and managed in primary care, however, underdiagnosis and suboptimal treatment are common.

The overall aim of this thesis was to assess the effect of a diagnostic-therapeutic approach for HF in older persons who presented to the general practitioner (GP) with shortness of breath on exertion in the previous year.

We performed a selective screening study in which 585 patients aged 65 years or over who presented themselves to the GP in the previous 12 months with shortness of breath on exertion underwent diagnostic investigations. Presence or absence of HF was established by an expert panel. The prevalence was similar for men and women (16.5% and 15.0% (p = 0.62), respectively. Prevalence rates were 2.9% (95% CI 1.8-4.7) for HF with reduced ejection fraction, 12.0% (95% CI 9.5-14.9) for HF with preserved ejection fraction, and 0.9% (95% CI 0.3-2.1) for isolated right-sided HF.

Then we developed a clinical prediction rule based on an existing one created in community-dwelling elderly with a GP’s diagnosis of chronic obstructive pulmonary disease. We validated, updated and extended the original model according to a standardised state-of-the-art stepwise approach in our population of community-dwelling elderly with shortness of breath. The final model with nine predictors resulted in a very good C-statistic of 0.88 (range 0.85 to 0.90), and a net reclassification improvement of 31.0%. We constructed a risk score for practical use. This risk score showed high accuracy with a negative predictive value of 87%, and a positive predictive value of 73%.

In addition, we performed a randomized clinical trial in which only the patients with newly detected HF participated. Randomization was on the level of the GP. Sixteen GPs were randomized to the care as usual group and 14 to the intervention group. The GPs in the latter arm received a single half-day interactive training in the management of HF. At baseline and after six months of follow-up, patients in both the intervention group (n=46) and care as usual group (n=46) were assessed on medication uptake, functionality, health status, and number of health care visits.After six months, uptake of HF medication and health status were similar in the two groups. Interestingly, patients in the intervention group had a longer walking distance with the six-minute walk test than those in the care as usual group (mean difference in all-type heart failure 28.0 (95% CI 2.9 to 53.1) meters). They also had more HF-related GP visits (RR 1.8, 95% CI 1.3 to 2.5), but fewer visits to the cardiologist (RR 0.6, 95% CI 0.3 to 1.1). In both arms, a substantial proportion of patients with HF with reduced ejection fraction were not treated according to guideline recommendations.