Valk MJ, Mosterd A, Broekhuizen BDL, et al.
British Journal of General Practice 2016; published online ahead of print

Background

Heart failure (HF) with reduced ejection fraction (HFrEF) is defined as symptoms and/or signs suggestive of HF, and a left ventricular ejection fraction (LVEF) ≤45%. The resulting morbidity and mortality can be managed with pharmacological treatment, devices, and special HF programmes [1].
HF with preserved ejection fraction (HFpEF) is defined as symptoms and/or signs suggestive of heart failure, and an LVEF ≥45% plus echocardiographic structural or functional cardiac abnormalities. Treatment for HFpEF patients is still lacking but symptoms can be alleviated with diuretics in cases with fluid retention [1]. The diagnosis of non-acute HF in early stages is difficult in primary care without echocardiography, therefore, HF is often over- or underdiagnosed by general practitioners (GPs) [2-8].
In this study, overdiagnosis of HF in primary care was evaluated by means of confirming HF diagnoses by an expert panel in 683 cases. The confirmation was based on the ESC HF guidelines [1]. Moreover, is was assessed which patient characteristics were associated with referral for echocardiography.

Main results

• Out of the 683 patients with a GP’s diagnosis of HF: 79.6% received cardiologist care, 17.8% was hospitalised for acute HF, 69.3% had usable natriuretic peptide measurements and 73.5% underwent echocardiography.
• Out of 683 patients with a GP’s HF diagnosis, according to the ESC guidelines: 118 patients had no HF (17.3%; 95% CI: 14.4 - 20.0), 131 patients had possible HF (19.2%; 95% CI: 16.3 - 22.2), 434 patients had definite HF (63.5%; 95% CI: 59.9-67.1).
• Compared to the 544 patients who received cooperative care involving a cardiologist, the 139 patients who received care from a GP only were significantly older (81.5 vs. 76.9 years; P <0.001), were less likely to have a history of myocardial infarction (10.8 vs. 31.4%; P <0.001), had echocardiography less often (30.9 vs. 84.4%; P <0.001), were less often prescribed an ACE-I or ARB (43.9 vs. 61.8%; P <0.001) and were less often prescribed MRAs (15.1 vs. 25.6%; P = 0.009).
• In multivariable analysis, younger age, history of MI and prescription of ACE-I or ARBs were independent predictors of referral for echocardiography.
• According to ESC guidelines, 434 patients had definite HF. Of these, 222 had HFrEF (32.5%; 95% CI: 30.9 - 34.1%), 207 had HFpEF (30.3%; 95% CI: 29.0 - 31.6%) and 5 had isolated right-sided HF (0.7%; 95% CI: 1.2 - 2.6).

Conclusion

More than one-third of HF diagnoses made in primary care, could not be confirmed by an expert panel judging according to the ESC guidelines. To avoid overdiagnosis of HF, access to echocardiography should be facilitated, and the cooperative care with a cardiologist should be optimised to promote drug use and to result in more intensive uptitration of drugs.

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