Management of chronic heart failure in the community: role of a hospital based open access heart failure service

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Abstract

Objective:

To evaluate the role of an open access heart failure service based at a teaching hospital for the diagnosis and treatment optimisation of patients with heart failure in the community and to identify measures that may further enhance the effectiveness of such a service.

Subjects:

963 patients with suspected heart failure seen over an eight year period referred by their general practitioners to the cardiology department at a district general hospital.

Main outcome measures:

Presence or absence of left ventricular systolic dysfunction (LVSD) (left ventricular ejection fraction < 50% on echocardiography), and determination of the risk factors and predictors of LVSD.

Results:

The majority of the patients were women (60%v 40%) and elderly (mean age 68.8 years). On echocardiography, only 30.8% were found to have LVSD. Patients were more likely to have LVSD if they were men (42.3%v 23.1%, p < 0.001, relative risk (RR) 1.8), were > 60 years of age (33.5%v 20.8%, p < 0.001, RR 1.6), or had a history of diabetes (49.4%v 29.1%, p < 0.001, RR 1.7), ischaemic heart disease (36.5%v 29.1%, p  =  0.04, RR 1.3), or atrial fibrillation (52.6%v 27.8%, p < 0.001, RR 1.9). An abnormal ECG (48.4%v 19.5%, p < 0.001, RR 2.5) and cardiothoracic ratio > 0.5 on chest radiograph (44.3%v 17.8%, p < 0.001, RR 2.5) were found to be good predictors of LVSD. A normal ECG (negative predictive value 80.5%) and a cardiothoracic ratio of < 0.5 (negative predictive value 82.2%) can be used as baseline measures to identify patients with lower risk of developing LVSD (combined negative predictive value 87.9%).

Conclusions:

An open access heart failure clinic is effective for the diagnosis and management of chronic heart failure in community based patients. The presence of risk factors and simple baseline tests can be used to identify patients with LVSD in the community. The introduction of a protocol based on these findings into a referral system can improve the efficiency and cost effectiveness of such a service.

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