Download Awareness and perception of heart failure among European

European Heart Journal (2008) 29, 1739–1752
doi:10.1093/eurheartj/ehn196
CLINICAL RESEARCH
Heart failure/cardiomyopathy
Awareness and perception of heart failure among
European cardiologists, internists, geriatricians,
and primary care physicians
1
Sticares Cardiovascular Research Foundation, PO Box 882, 3160 AB Rhoon, The Netherlands; 2University of Glasgow, Glasgow, UK; 3Primary Care Clinical Sciences, University of
Birmingham, Birmingham, UK; 4Hôpital Lariboisière, Paris, France; 5Hospital Universitario Gregorio Maranon, Madrid, Spain; 6Ospedale S. Giovanni-Addolorata, Rome, Italy; 7CHU
Nancy Hôpital de Brabois, Nancy, France; 8Institut für Herzinfarktforschung, Ludwigshafen am Rhein, Germany; 9Institulul de Boli Cardiovasculare, ‘C.C.Iliescu’, Bucharest, Romania;
10
National Institute of Cardiology, Warsaw, Poland; 11Karolinska University Hospital, Stockholm, Sweden
Received 20 December 2007; revised 9 April 2008; accepted 17 April 2008; online publish-ahead-of-print 27 May 2008
See page 1706 for the editorial comment on this article (doi:10.1093/eurheartj/ehn256)
Aims
To assess awareness of heart failure (HF) management recommendations in Europe among cardiologists (C), internists and geriatricians (I/G), and primary care physicians (PCPs).
.....................................................................................................................................................................................
Methods
The Study group on HF Awareness and Perception in Europe (SHAPE) surveyed randomly selected C (2041), I/G
(1881), and PCP (2965) in France, Germany, Italy, the Netherlands, Poland, Romania, Spain, Sweden, and the UK.
and results
Each physician completed a 32-item questionnaire about the diagnosis and treatment of HF (left ventricular ejection
fraction ,40%). This report provides an analysis of HF awareness among C, I/G, and PCP. Seventy-one per cent I/G
and 92% C use echocardiography, and 43% I/G and 82% C use echo-Doppler as a routine diagnostic test (both
P , 0.0001). In contrast, 75% PCP use signs and symptoms to diagnose HF. Fewer I/G would use an angiotensinconverting enzyme (ACE)-inhibitor in .90% of their patients (64 vs. 82% C, P , 0.0001), whereas only 47% PCP
would routinely prescribe an ACE-inhibitor. Worsening HF was considered a risk of ACE-inhibitor therapy by
35% PCP. I/G and PCP consistently do not prescribe target ACE-inhibitor doses (P , 0.0001 vs. C). Only 39% I/G
would use a b-blocker in .50% of their patients (vs. 73% C, P , 0.0001). Also, only 5% PCP would always, and
35% often, prescribe a b-blocker and reach target doses in only 7 –29%. Moreover, 34% PCP and 26% I/G vs.
11% C (P , 0.0001) do not start a b-blocker in patients with mild HF, who are already on an ACE-inhibitor and
are on diuretic. In mild, stable HF, 39% PCP and 18% I/G would only prescribe diuretics, vs. 7% C (P , 0.0001).
In patients with worsening HF in sinus rhythm and on an optimal ACE-inhibitor, b-blockade and diuretics, significantly
more C would add spironolactone, but I/G would more often add digoxin.
.....................................................................................................................................................................................
Conclusion
Although each physician group lacks complete adherence to guideline-recommended management strategies, these
are used significantly less well by I, G, and PCPs, indicating the need for education of these essential healthcare
providers.
----------------------------------------------------------------------------------------------------------------------------------------------------------Keywords
Heart failure † Awareness † Perception † Europe † Guidelines † Diagnosis † Treatment † Advice †
Cardiologists † Internists † Geriatricians † Primary care physicians † ACE inhibition † b-Blockade †
Aldosterone antagonists † Diuretics † Echocardiography † Heart failure nurses
* Corresponding author. Tel: þ31 10 485 51 77, Fax: þ31 10 485 48 33, Email: [email protected]
Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2008. For permissions please email: [email protected].
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Willem J. Remme 1*, John J.V. McMurray 2, F.D. Richard Hobbs 3, Alain Cohen-Solal 4,
José Lopez-Sendon5, Alessandro Boccanelli6, Faiez Zannad 7, Bernhard Rauch 8,
Karen Keukelaar 1, Cezar Macarie 9, Witold Ruzyllo10, and Charles Cline 11 for the
SHAPE Study Group
1740
Introduction
Methods
The rationale and design of the SHAPE study have been previously
published in detail.16 The study was carried out in France, Germany,
Italy, the Netherlands, Poland, Romania, Spain, Sweden, and the UK,
and aimed at including at least 300 PCP, 150 C, and 150 I/G combined
per country. For the PCP survey, a questionnaire containing 33 questions was developed to gather PCPs’ knowledge of HF (including
prevalence, aetiology, new diagnostic and therapeutic developments,
and healthcare costs); the diagnostic procedures and treatments
carried out by the PCPs in their own practices, their referral patterns
for diagnostic procedures and specialist care; and the type of practice
and number of patients in each primary care practice. The questionnaires sent to C, I, and G (in combination referred to as specialists)
contained 32 questions covering epidemiology, aetiology, and diagnostic and therapeutic strategies in congestive heart failure (CHF), as well
as some demographic and practice-related questions. In both questionnaires, treatment questions were specifically about CHF with a
reduced left ventricular ejection fraction (,40%). Where applicable,
respondents were requested to indicate their order of preference
for a diagnostic or therapeutic intervention and the questions were
based on the available European guidelines on diagnosis and treatment
of HF. The questions were ordered so as not to influence answers. The
questionnaires were piloted for reliability and validity, and final versions translated into each country’s native language and checked for
content and accuracy of translation by native-speaking physicians of
the relevant countries and members of the SHAPE study group.
Questionnaires were coded by country and individual physician to
preserve anonymity.
Primary care physician survey
A total of 18 000 PCPs were randomly selected from the nine
countries. The minimum number of completed questionnaires
required per country was set at 300. Assuming a 15% response rate,
questionnaires were mailed to 2000 PCPs per country, randomly
selected using a pre-specified algorithm from lists of all PCPs received
from the respective PCP organizations in each country. In countries
where the response was ,15% in the first round, a second mailing
was done following a second random selection from the remaining
PCPs, the number based on the response rate from the first mailing.
In Italy, Romania, Sweden, and the UK, one mailing was sufficient. In
the other countries, between 2139 (Spain) and 3881 (Germany) questionnaires were sent out in total.
Specialist survey
To achieve a minimum of 300 completed questionnaires per country
(at least 150 C and 150 I/G), the questionnaire was sent to all specialists, in countries with 1500 specialists (using computer lists containing the names, specialization and addresses of each specialist), whereas
in other countries a random selection of 1500 physicians (50% C and
50% I/G) was made using computer algorithms. If the response rate following the first mailing was insufficient, a second mailing, excluding
responders to the first, followed. The number of questionnaires sent
out during the second mailing was based on the percentage response
(per specialist group) to the first mailing in a particular country, if sufficient additional addresses were available. If not, the complete mailing
was repeated. Due to meagre responses to the first mailing, a second
one was carried out in all countries.
The first questionnaires of the PCP and specialist surveys were sent
out between October 2002 and January 2003. The databases were
closed in June 2003.
Data analysis
The database was created in Microsoft Access. All questionnaires were
single-entered into this database and checked for inconsistencies. In
addition, one out of 15 records was double-entered and was
checked for data entry mistakes. After closing the database, variables
were recoded where appropriate. Results were tabulated in a descriptive way. For each possible answer, the counts and proportions were
given for the separate countries and the overall total. To test the differences between C and I/G, within each physician group, and between
countries, the Chi-square test was used. Countries with nonoverlapping confidence intervals were considered different from
each other. For all analyses, a value of P , 0.01 was considered significant. All analyses were performed with STATA version 6.0.
Results
Response rate
Completed questionnaires were returned by 2041 C and 1881 I/G
(29% of these were geriatricians). Response rates for C varied
from 11% (160) in Spain to 35% (182) in the Netherlands
(overall 25%) and for I/G between 11% (the Netherlands, 156
I/G) and 40% (Romania, 73 I/G) (overall 18%). Completed questionnaires were available from 2965 PCP. The average response rate
overall was 13% and varied between countries, with the highest
response from Romania (23% to the first mailing, 462 PCP) and
Downloaded from http://eurheartj.oxfordjournals.org/ at Pennsylvania State University on March 5, 2014
Two decades of controlled clinical trials have led to significant
developments in drug and device treatment of heart failure (HF).
When and how to apply these evidence-based treatments is
detailed in several international guidelines.1,2 These guidelines
also provide recommendations on diagnostic investigations and
non-pharmacological treatments, including lifestyle advice, exercise, and surgery. Despite the availability of guidelines for more
than a decade in Europe,1,3 – 5 HF management still appears to be
suboptimal, possibly because physicians do not implement guideline recommendations. Whereas surveys have been carried out
among cardiologists (C) in Europe,6 the picture among internists
(I) and geriatricians (G) is not clear, and a detailed comparison
between different specialists involved in HF care across Europe
is lacking.7 In contrast, previous surveys have clearly indicated
that adherence to guideline-recommended practice is low among
primary care physicians (PCPs).8,9 However, the most recent and
largest of these studies, IMPROVEMENT-HF,9 started in 1999,
around the time evidence was emerging of the benefit of
b-blockers and spironolactone in addition to ACE-inhibitors to
treat HF.10 – 13 Subsequently, other non-pharmacological treatments have been shown to reduce morbidity and mortality.14,15
Since these surveys, new national and international evidence-based
guidelines have been published and widely disseminated. It is
appropriate therefore to re-examine contemporary understanding
of and attitudes to HF treatment in Europe.
The Study of HF Awareness and Perception in Europe (SHAPE)
was designed to evaluate HF awareness among the general public
and physicians involved in HF care. Here, the findings among C, I,
G, and PCP are compared across nine European countries.
W.J. Remme et al.
1741
Awareness and perception of heart failure
the lowest from France and Germany (9% response rate each over
two mailings, 292 and 331 PCPs, respectively).
Diagnosis of congestive heart failure
Specialists
Only 71% I/G indicated that they would routinely perform an echo
and 43% an echo-Doppler, compared with 92 and 82% C, respectively (both P , 0.0001) (Table 1).
Nearly all C and I/G performed a 12-lead ECG and chest X-ray
routinely, but other investigations only on clinical indication.
However, there were significant between-country differences
(Table 1).The use of natriuretic peptides was low overall. More
than one-third of C and I/G would not use natriuretic peptides
for the diagnosis of HF.
Pharmacotherapy
Angiotensin-converting enzyme-inhibitors
Significantly fewer I/G than C indicated that they use an
ACE-inhibitor in 90% of their patients (64 vs. 83% C, P ,
0.0001, Table 4) and only 43% PCP would always (51% often) prescribe an ACE-inhibitor (Table 5); 13% I/G and 24% PCP would not
prescribe an ACE-inhibitor in asymptomatic patients with LV dysfunction already on a diuretic (vs. 4% C, P , 0.0001). Also, more C
than I/G and PCP would reach target doses of ACE-inhibitors
(Figure 1).
Approximately half of all C and I/G considered renal impairment,
hypotension and hyperkalaemia a high risk of ACE-inhibitor use
and approximately 25% C and 30% I/G would stop or adapt
therapy in these instances. PCPs were less concerned, except for
cough (55%) (Figure 2). Thirty-eight per cent C and 35% I/G
would change or stop (and 47% PCP stop) treatment because of
cough. Of interest, quite a few physicians in each group believed
that ACE-inhibitors carried some risk of bronchospasm, cold
extremities, impotence, and even worsening HF.
b-Blockers
Only 5% PCP stated that they would always and 35% often prescribe a b-blocker (although there were considerable betweencountry differences, Table 5) and 11% would never prescribe it.
Other pharmacotherapy
The majority of C and I/G stated that they would prescribe an
angiotensin receptor blocker (ARB) only in case of intolerance
to ACE inhibition. Less than 10% reported adding an ARB to an
ACE-inhibitor with persisting symptoms (PCP 7%). Significantly
more Dutch C (37%) and I/G (46%) would use an ARB as a
routine alternative to ACE inhibition (compared with C and I/G
in other countries).
Most C and I/G indicated that they would prescribe digoxin in
mild (NYHA I– II) HF only in selected cases (e.g. those with
atrial fibrillation). Conversely, approximately half of C and I/G
would prescribe digoxin regularly (i.e. in .30%) in patients with
NYHA III and IV HF. Slow-release dihydropyridine calcium antagonists were prescribed by significantly more I/G (30%) than C
(15%) in .10% of their patients. Also, significantly more I/G
than C would use verapamil or diltiazem in .10% of their patients
(31 vs. 5%, respectively).
Prescription rates for digoxin, aldosterone antagonists and
nitrates by PCP mimicked those for b-blockers, although there
were considerable between-country differences (Table 5).
Order of treatment
Primary care physician
Diuretics were the preferred single agent for initiation of treatment
(Table 7). ACE-inhibitors (either alone or in combination with a
diuretic) would be used to initiate treatment by only just over
50% of respondents. An average 34% of respondents would add
a b-blocker in a patient who continued to have symptoms or worsened despite optimal treatment with a diuretic and an
ACE-inhibitor. More would prescribe spironolactone (44%) or
digoxin (38%), and approximately 50% would refer the patient
for specialist care.
Specialists
In mild –moderate, stable HF without signs of fluid retention, 58%
C and 64% I/G reported they would start treatment with an
ACE-inhibitor, whereas 25% C would start with an ACE-inhibitor
and a b-blocker, up-titrated one after the other (vs. 13% I/G,
P , 0.001). Few would start with only b-blockade.
If signs of fluid retention were present, most C and I/G (48 and
50%, respectively) would start with a diuretic only, and 40% C and
37% I/G with a diuretic and an ACE-inhibitor at the same time.
Downloaded from http://eurheartj.oxfordjournals.org/ at Pennsylvania State University on March 5, 2014
Primary care physician
Seventy five per cent PCP reported that they often or always diagnosed HF by signs and symptoms alone (and 21% often or always
by symptoms alone) (Table 2). Only 35% would often arrange for
further investigations, whereas 22% thought that a response to
diuretics was necessary to confirm the diagnosis. Only 9% PCP
reported that they would reach a diagnosis of HF after referral
to a specialist. Approximately 60% of respondents considered an
ECG, chest X-ray, and echocardiogram necessary for diagnosis
(Table 2). Again, the proportion varied by country. Echocardiography was considered necessary by 85% of Italian compared with
49% of Dutch PCPs.
Only 50% could obtain an echocardiogram directly (16%) or via
specialists (34%) within 1 month compared with 94% and 91% for
an ECG or a chest X-ray, respectively (Table 3). There were large
differences between countries. Direct access to echocardiography
was poor in nearly all countries.
Moreover, target doses of b-blockade would only be reached in
seven (metoprolol) to 29% (carvedilol) of cases. Also, considerably
fewer I/G (39%) than C (73%) would prescribe a b-blocker in
50% of their patients (P , 0.0001) (Table 4). More I/G (26%)
than C (11%, P , 0.0001) and 35% PCP indicated that they
would not treat patients with mild HF already on an ACE-inhibitor
and a diuretic with a b-blocker. Conversely, only 45% PCP would
not prescribe this treatment to a patient with unstable HF. Significantly less I/G than C would prescribe a b-blocker in case of old
age, NYHA class IV, a systolic blood pressure ,100 mmHg,
heart rate ,60 beats/min and chronic obstructive pulmonary
disease (COPD) (Table 4), whereas .80% of PCP would not prescribe in case of bradycardia and COPD (Table 6).
1742
Table 1 Diagnostic procedures in a patient with a clinical suspicion of heart failure of unknown aetiology by European specialists
Cardiologists
....................................................................................................
Internists/Geriatricians
..................................................................................................
Nl
Fr
Sp
It
Ro
UK
Sw
Pl
Ge
All
Nl
Fr
Sp
It
Ro
UK
Sw
Pl
Ge
All
99
1
100
0
99
1
100
0
99
1
100
0
99
1
99
1
99
1
99
1
97
3
93
5
97
2
96
2
99
0
99
1
98
1
99
0
99
1
98
1
0
0
0
0
0
0
0
0
0
0
0
1
1
0
0
0
0
0
0
0
87
11
68
24
96
4
90
8
92
5
90
9
50*
46*
90
10
39*
52*
79
18
94
6
87
12
97
3
92
5
93
7
97
2
64
31*
90
8
61
33*
0
4
0
0
1
0
2
1
5
1
0
1
1
1
0
0
2
0
2
1
94
2
88
6
91
6
92
4
84
14
94
5
91
7
94
5
98
0
92
5
60
29
64
19
77
14
74
11
82
12
81
11
59
32
79
18
65
23
71#
19
Not perform
4
6
3
4
2
1
2
1
2
3
2
7
2
1
0
0
0
0
1
2
Echo Doppler (%)
Routine
88
83
85
82
57*
88
76
78
94
82
27*
47
48
52
64
37
26*
47
48
43#
...........................................................................................................................................................................................................................................
ECG (%)
Routine
Clinical indication
Not perform
...........................................................................................................................................................................................................................................
Chest X-ray (%)
Routine
Clinical indication
Not perform
85#
12
...........................................................................................................................................................................................................................................
Echo (%)
Routine
Clinical indication
...........................................................................................................................................................................................................................................
Clinical indication
8
9
13
12
33
8
20
19
5
13
60*
38
41
39
23
34
56
45
43
43
Not perform
0
2
1
0
5
1
1
1
0
1
5
6
5
1
7
14
7
4
3
6
Exercise test (%)
Routine
42
11
4
11
13
12
18
19
59*
19
18
9
7
10
14
10
16
20
49*
17þ
...........................................................................................................................................................................................................................................
Clinical indication
51
70
75
64
74
81
65
75
34*
67
64
76
77
61
63
74
58
71
39*
64
Not perform
3
12
16
19
11
3
12
4
3
9
12
13
12
22
21
10
15
5
5
12
ExerciseþVO2 (%)
Routine
3
6
1
7
1
4
2
2
7
4
1
3
2
3
0
0
2
2
4
2#
Clinical indication
58
46
47
59
26*
45
48
41
49
47
44
47
40
49
25
35
34
18*
49
39
Not perform
30
42
40
19*
64
44
42
48
32
39
44
44
48
25
64
51
51
70
30
46
18
15
8
34
4
10
3
27
49
18
4
9
5
25
4
6
2
21
40*
15þ
76
70
84
58
79
87
89
69
48
74
86
61
88
68
73
88
74
73
54
73
4
11
6
3
13
1
5
2
1
5
6
26
4
2
15
2
16
3
1
7
Right heart cath (%)
Routine
7
2
0
0
1
3
1
1
1
2
0
0
0
0
1
0
0
0
0
0#
Clinical indication
76
51
74
57
46
84
55
53
61
63
68
40
68
44
36
43
23*
29
60
45
Not perform
13
41
20
34
45
10
38
38
30
29
24
54
24
39
52
43
63
60
30
43
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
Holter (%)
Routine
Clinical indication
Not perform
...........................................................................................................................................................................................................................................
W.J. Remme et al.
...........................................................................................................................................................................................................................................
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1743
Abbreviations: BNP, brain natriuretic peptide; CAG, coronary angiography; cath, catheterization; Fr, France; Ge, Germany; It, Italy; Nl, Netherlands; Pl, Poland; Ro, Romania; Sp, Spain; Sw, Sweden; UK, United Kingdom.
*P , 0.01 vs. other countries, þP , 0.01, †P , 0.001, #P , 0.0001 cardiologists vs. internists/geriatricians.
33
36
13†
9
45
26
13
8
36
39
11
19
54
8
42
18
31
44
21
20
10
13
19
34
37
46
26
18
17
32
42
39
42
14
14
18
58
22
44
16
24
47
12*
35
18
30
37
25
Clinical indication
Not perform
14
26
Routine
BNP/proBNP (%)
33
49
83
5
85
1
94
1
79
7
81
0
69
26*
86
7
86
7
83
2
82
1
Clinical indication
Not perform
39
39
86
8
82
10
73
18
38
14
11*
56
26
48
...........................................................................................................................................................................................................................................
75
16
84
9
79
13
57
31*
76
16
68
22
70
20
2
1
1
1
1
6
1
11
11
4
12
18
1
5
9
14
15
Routine
CAG (%)
When asked whether, in mild HF (NYHA class I–II), diuretics alone
are sufficient, 18% I/G agreed (31% in Germany) vs. 7% C (P , 0.001).
Worsening HF symptoms in a patient in sinus rhythm and
already receiving optimal doses of ACE inhibition, b-blockade
and diuretics would prompt more C than I/G to add spironolactone, whereas more I/G would add digoxin (Figure 3).
Referral to a specialist
Only 55% PCP would send patients with mild-to-moderate HF,
aged 65 –80 years, to a specialist and only 32% would refer patients
over 80 years (10% in the Netherlands).
How medical specialists obtain
information on heart failure
Although guidelines scored the highest among C, they were only
chosen by 32%, followed by expert opinion (30%), and review
articles (18%). Expert opinion scored the highest among I/G
(31%), whereas only 27 and 21% selected guidelines and
review articles, respectively. Guidelines scored the highest in the
Netherlands, but very low in Romania where expert opinion was
particularly highly regarded.
Discussion
This survey into the awareness and perception of different aspects
of HF among C, I/G and PCP in nine European countries, selected
to represent Europe geographically, indicates that, despite widespread availability of evidence-based HF guidelines, differences
between physicians and countries exist in HF management.
These differences were particularly apparent in the necessity to
determine cardiac function (in particular the use of echocardiography as a routine diagnostic tool), prescription of ACE inhibition
and b-blockade, use of low doses of these agents, reliance on
diuretics as single treatment in HF, use of inappropriate drugs,
and timing of medication.
The SHAPE survey is the only prospective multi-country
European study to provide a comparison between awareness
and perception of HF among C and I, and a contemporary analysis
of those of PCPs in the same countries.
There are several prior between-specialist comparisons of HF
management from single countries in Europe, which have reported
differences in practice. A French study, conducted in 1997, showed
no difference in the use of echocardiography and ACE-inhibitors
by I compared with C but both were used less by geriatricians.17
In contrast, an Italian study, conducted in 1998, showed higher
rates of the use of echocardiography, ACE-inhibitors, and
b-blockers (and adherence to guidelines) by C compared with
I.18 The only prior multinational data come from the Euro HF I
study that provided information on ACE-inhibitor and b-blocker
use at discharge from cardiology and general internal medicine
wards in 24 European countries in 2000– 1. These drugs were prescribed significantly less often in patients discharged from internal
medicine wards.7 Because, however, the patients discharged from
these two types of wards differed (those from internal medicine
wards were older, had more co-morbidity, etc.), it was difficult
to know whether the prescribing differences reflected physician
knowledge and practice or patient characteristics.19 Our data
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0
3
2#
Awareness and perception of heart failure
1744
W.J. Remme et al.
Table 2 Diagnostic procedures European PCPs use to detect heart failure
NL
Fr
Sp
It
Ro
UK
Sw
Pl
Ge
Total
...............................................................................................................................................................................
Of those patients that YOU have diagnosed with heart failure, how did you come to that conclusion?
Response rate (n)
Non-responders
309
2
292
0
298
1
300
1
460
2
375
3
288
2
301
0
331
0
2954
11
Never (%)
Occasionally (%)
15
43
17
39
32
42
16
34
29
26
42
41
30
52
33
33
15
34
26
38
Often (%)
34
34
17
29
14
11
14
14
30
21
Never (%)
Occasionally (%)
3
16
2
22
0
17
1
16
2
20
3
27
4
41
1
16
1
10
2
20
Often (%)
80
73
82
79
74
69
55
83
88
75
...............................................................................................................................................................................
On symptoms alone
...............................................................................................................................................................................
On symptoms plus signs
Only after further investigations
Never (%)
Occasionally (%)
2
62
6
43
9
40
3
28
3
32
1
38
1
40
1
37
2
29
3
38
Often (%)
27
31
37
29
26
51
47
31
40
35
5
89
12
70
17
69
13
53
4
49
6
83
19
71
18
47
7
67
10
66
3
6
3
10
21
3
4
8
15
9
...............................................................................................................................................................................
Only after referral to hospital specialist
Never (%)
Occasionally (%)
Often (%)
...............................................................................................................................................................................
When you investigate a patient with possible heart failure which tests do you believe are necessary and which tests so you believe are supportive to
diagnose heart failure? (indicate all that apply)
Response rate (n)
309
290
298
300
458
376
285
301
331
2948
2
2
1
1
4
2
5
0
0
17
Not applicable (%)
14
13
2
4
4
12
6
1
6
7
Supportive (%)
Necessary (%)
58
28*
14
73
40
58
29
66
21
74
64
24*
48
46
11*
88
29
65
35
58
2
22
0
8
3
3
5
1
0
5
45
53
22
56
25
75
31
61
19
77
57
39
61
34
11
87
35
65
34
61
Non-responders
...............................................................................................................................................................................
ECG
...............................................................................................................................................................................
Chest X-ray
Not applicable (%)
Supportive (%)
Necessary (%)
...............................................................................................................................................................................
Echocardiography
Not applicable (%)
10
3
2
2
5
2
3
1
4
4
Supportive (%)
Necessary (%)
43
47
46
51
37
61
13
85
37
58
29
69
22
75
26
73
32
64
32
64
9
30
13
37
18
21
17
15
14
19
61
30
47
23
60
26
45
18
51
31
67
12
74
9
64
21
62
24
59
22
...............................................................................................................................................................................
Response to diuretics
Not applicable (%)
Supportive (%)
Necessary (%)
*P , 0.01 vs. other countries. Abbreviations as in Table 1.
suggest that the different treatment of patients discharged from
internal medicine and cardiology wards, at least in part, reflects
differences between specialists in their perception of the diagnosis
and treatment of patients with HF.
PCPs’ perception of recommended diagnostic approaches and
treatment options in HF are of concern. Most think that diagnosis
can be made on the basis of symptoms and signs alone. Although
64% of PCPs consider an echocardiogram necessary and 32% supportive to establish the diagnosis of heart failure (a figure not too
different from the 92% of specialists who perform echocardiography routinely in this case), only one-third would often arrange for
it to diagnose HF. This might be at least partly explained by the
Downloaded from http://eurheartj.oxfordjournals.org/ at Pennsylvania State University on March 5, 2014
...............................................................................................................................................................................
1745
Awareness and perception of heart failure
Table 3 PCPs’ access to diagnostic tests for heart failure
NL
Fr
Sp
98
76
99
14
56
4
1
3
0
4
2
5
0
0
0
It
Ro
UK
Sw
Pl
Ge
Total
66
39
93
90
22
99
75
31
38
8
1
2
9
19
10
6
2
1
5
1
3
4
10
4
1
1
1
4
0
2
1
0
0
0
0
...............................................................................................................................................................................
ECG
Access within 1 month
Direct (%)
Through specialist (%)
...............................................................................................................................................................................
Access at 1– 3 months
Direct (%)
Through specialist (%)
Not available
...............................................................................................................................................................................
Chest X-ray
Access within 1 month
Direct (%)
Through specialist (%)
98
77
95
67
27
98
70
25
34
65
14
50
4
29
45
4
9
3
68
26
1
4
2
2
0
4
5
4
3
8
1
4
15
3
9
1
1
2
5
4
0
0
0
0
1
0
0
1
2
0
...............................................................................................................................................................................
Access at 1– 3 months
Direct (%)
Through specialist (%)
Not available
...............................................................................................................................................................................
Echocardiography
...............................................................................................................................................................................
Access within 1 month
Direct (%)
Through specialist (%)
15
41
5
26
4
16
14
11
18
16
3
75
11
25
44
8
11
25
72
34
7
44
8
8
9
35
9
35
2
21
26
29
26
37
11
25
3
14
14
26
13
1
14
0
41
1
1
8
3
6
...............................................................................................................................................................................
Access at 1– 3 months
Direct (%)
Through specialist (%)
Not available
Abbreviations as in Table 1.
availability of echocardiography; in most countries, echocardiography was not available to more than half of the PCPs within 1
month, or not available at all (e.g. Romania), and this would
obviously impact on their usage by the PCP. It is very disappointing
that lack of access may still be a problem, as this had been
highlighted in earlier surveys such as the Euro-HF study8 (which,
like SHAPE, was a questionnaire-based survey) and in the
IMPROVEMENT-HF study9 (interview-based and an actual practice
survey) which were conducted almost a decade ago. Of interest, in
the IMPROVEMENT study, 48% PCPs reported to routinely use an
echo for the diagnosis of HF20 as compared with our later survey,
in which only 35% indicated to often arrange for investigations,
including echo. Whether this failure to improve over time is the
fault of healthcare providers (to recognize this as a public health
problem and provide funding and resources), secondary care
physicians (to be interested in the problem of HF in the community
and provide service to their primary care colleagues) or PCPs
(to recognize the need for echocardiography and demand its
availability), or some combination of these, is unknown. Clearly,
this needs to be identified and resolved before the most valuable
diagnostic investigation is made universally available to European
HF patients.
Our results also show that HF treatment in primary care has
changed little due to the previous surveys.8,9 PCPs still do not
follow the European and other guidelines, which consistently recommend ACE-inhibitors as first-line therapy for all patients with
reduced left ventricular systolic function.3 – 5 Indeed, we found
that many respondents stated that they would start their treatment
with only a diuretic and less than half of them perceived the need
to use ACE-inhibitors in all HF.
That b-blockers further reduce morbidity and mortality when
added to an ACE-inhibitor became evident in 199911,12 and was
clearly stated in guidelines available before our survey.3,4 Despite
this, only 5% PCPs in SHAPE state that they would always (and
35% often) prescribe a b-blocker. Indeed, 11% would never prescribe a b-blocker and 35% would not prescribe it to a patient
with mild symptoms on treatment with an ACE-inhibitor and
diuretic. Moreover, a large majority of physicians reported that
they would not reach the recommended target dosages of
ACE-inhibitors or b-blockers.4 One contributing reason may be
that there is a general concern and over-estimation of the risk of
side-effects with these drugs,8 increasing the likelihood of not
starting them or inappropriate dosing. These concerns were
expressed by PCPs and I/G (more than by C). Changes in blood
Downloaded from http://eurheartj.oxfordjournals.org/ at Pennsylvania State University on March 5, 2014
...............................................................................................................................................................................
1746
Table 4 Prescription of ACE-inhibitors and b-blockers by European specialists
Cardiologists
.............................................................................................
Internists/Geriatricians
............................................................................................
NL
Fr
Sp
It
Ro
UK
Sw
Pl
Ge
All
Nl
Fr
Sp
It
Ro
UK
Sw
Pl
Ge
All
.90% of patients
87
85
81
83
68*
85
79
78
90
83
71
59
68
68
70
65
44*
79
62
64#
50–90%
12
13
17
17
25
15
20
21
10
16
23
31
25
27
21
32
44
19
32
29
30–50%
,30%
1
0
1
0
3
0
1
0
5
2
0
0
1
0
1
1
0
0
1
0
5
1
7
4
6
1
5
0
8
1
3
0
10
2
1
1
6
0
6
1
.90% of patients
50–90%
37
47
23
38
21
45
11
41
23
43
26
52
47*
42
30
48
56*
39
29
44
8
21
8
17
6
25
5
19
16
40
5
21
14
33
21
39
16
38
11#
28
30–50%
13
27
26
38
21
19
8
17
5
21
29
13*
30
39
29
29
30
25
30
29
10–30%
,10%
2
1
10
2
6
1
7
2
8
5
4
0
3
0
2
3
0
0
5
1
27
15
24
39*
28
12
26
11
5*
10
30
15
18
5
10
6
10*
6
20
12
No symptoms þ diuretics
5
3
5
4
10*
1
3
8
1
4
19
15
7
7
10
10
19
9
20
13#
Creatinine .200 mmol/L
SBP , 100 mmHg
33
21
37
45
56
55
41
15
57
59
40
19
47
20
38
54
29
31
41
33
31
34
48
53
46
53
45
24*
66
64
57
53
65
44
47
55
38
40
49#
45#
...........................................................................................................................................................................................................................................
Do you use an ACEi (%) in
...........................................................................................................................................................................................................................................
Do you use a BB(%) in
...........................................................................................................................................................................................................................................
ACEi are not prescribed (%)
Old age (.70 years)
0
0
1
0
0
0
2
0
1
1
1
1
1
3
0
0
1
2
1
5
30
14
39
15
69
14
59
15
47
9
18*
22
15*
19
49
13
45
14
39
8
41
14
33
7
52
17
65
26
51
16
22*
27
29
20
53
15
55
17
45þ
9
11
14
14
18
7
11
12
6
11
19
35
23
29
15
31
29
21
24
26#
Heart rate , 60 beats/min
Old age (.70 years)
19
1
6
1
9
1
12
1
17
11*
13
1
9
0
15
3
6
0
12
2
33
3
23
8
24
3
24
13*
23
10
18
4
17
3
24
3
18
2
22#
5#
COPD
42
73
72
75
51
53
30
64
46
58
64
67
78
70
51
78
40*
65
74
68#
SBP ,100 mmHg
Unstable HF
20*
53
41
75
42
75
52
52
40
63
18
74
30
47
45
48
29
63
35
62
38
37
55
57
48
70
50
34
52
66
41
68
51
43
51
43
39
46
47#
50#
NYHA IV HF
25
37
30
30
32
18
18
15
24
29
31
35
35
41
33
14*
33
35
31#
Serum sodium ,130 mmol/L
Cough
7*
...........................................................................................................................................................................................................................................
BB not prescribed (%)
Mild HF þ ACEi/diuretic
8*
W.J. Remme et al.
ACEi, ACE-inhibitor; BB, b-blocker; COPD, Chronic obstructive pulmonary disease; HF, heart failure; NYHA, New York Heart Association classification; SBP, systolic blood pressure. Other abbreviations as in Table 1.
*P , 0.01 vs. other countries, þP , 0.01, †P , 0.001, #P , 0.0001 cardiologists vs. internists/geriatricians.
Downloaded from http://eurheartj.oxfordjournals.org/ at Pennsylvania State University on March 5, 2014
1747
Awareness and perception of heart failure
Table 5 PCPs’ estimation on how often they prescribe the following drugs
NL
Fr
Sp
It
Ro
UK
Sw
Pl
Ge
Total
309
292
298
300
460
375
288
301
331
2954
2
0
1
1
2
3
2
0
0
11
...............................................................................................................................................................................
Response rate (n)
Non-responders (n)
...............................................................................................................................................................................
Diuretic
Never (%)
0
0
0
0
0
1
0
0
0
0
Occasionally (%)
Often (%)
2
61
2
39
2
54
6
28
2
40
3
61
4
59
3
62
4
56
3
51
Always (%)
37
59
44
66
58
36
37
35
40
46
Never (%)
Occasionally (%)
11
74
5
41
7
63
2
33
1
12
7
82
9
81
0
52
4
60
5
53
Often (%)
15
49
26
45
47
11
10
43
33
32
Always (%)
0
5
4
21
41
0
0
4
4
10
b-Blocker
Never (%)
...............................................................................................................................................................................
Digoxin
22
15
18
12
8
22
3
1
2
11
Occasionally (%)
56
50
51
49
56
58
50
34
30
48
Often (%)
Always (%)
20
2
30
5
30
2
33
6
30
7
19
1
43
4
56
9
58
11
35
5
...............................................................................................................................................................................
ACE-inhibitor
Never (%)
0
1
1
0
0
0
1
0
0
0
Occasionally (%)
Often (%)
7
62
9
52
6
50
3
42
10
48
3
61
6
59
4
34
4
50
6
51
Always (%)
31
37
43
55
42
36
34
62
45
43
46
48
28
54
38
51
32
49
19
66
53
41
49
43
19
66
29
58
34
53
Often (%)
6
18
10
17
13
6
7
13
13
11
Always (%)
0
1
1
2
2
0
0
2
1
1
Never (%)
14
20
9
7
66
7
3
35
5
19
Occasionally (%)
Often (%)
63
21
50
28
69
21
46
40
29
4
72
21
64
30
59
5
62
29
57
22
2
2
1
7
1
0
3
1
4
2
Never (%)
Occasionally (%)
7
57
9
46
17
57
7
45
6
36
20
63
15
52
2
39
19
56
11
50
Often (%)
33
39
25
37
42
17
30
52
21
33
Always (%)
2
5
1
11
16
0
3
7
4
6
...............................................................................................................................................................................
Calcium antagonist
Never (%)
Occasionally (%)
...............................................................................................................................................................................
Angiotensin_II antagonist
Always (%)
...............................................................................................................................................................................
Nitrates
...............................................................................................................................................................................
Aldosterone receptor antagonist
Never (%)
9
4
6
11
4
5
4
1
4
5
Occasionally (%)
55
34
54
40
50
71
61
22
69
51
Often (%)
Always (%)
32
3
56
6
36
4
36
12
39
8
23
1
32
2
67
11
26
2
38
5
P , 0.01 vs. other countries. Abbreviations as in Table 1.
pressure and serum creatinine are usually small with ACE inhibition
in normotensive patients without severe HF, and symptomatic
hypotension is uncommon. Also, whereas b-blockade may lead
to worsening HF, bradycardia, and hypotension in a few patients,
these effects are usually not dangerous, and are rapidly reversible,
provided that patients are stable and up-titration is slow, starting
Downloaded from http://eurheartj.oxfordjournals.org/ at Pennsylvania State University on March 5, 2014
...............................................................................................................................................................................
1748
Figure 2 European primary care physicians perception of the
risks of ACE-inhibitor treatment (A) and b-blocking therapy (B)
in heart failure (striped bar: high risk; closed bar: low risk; open
bar: no risk).
from a low dose. In MERIT-HF21 study, blood pressure in patients
receiving b-blockade fell less than in the placebo group. Furthermore, there is a misconception that bronchospasm often occurs
with b-blockade in HF. Combined non-selective b- and a-adrenergic
blockade is well tolerated in HF patients with COPD.22
Only 50% PCPs said that they would refer a patient in the
typical age range of HF (65 –80 years) to a specialist, and few
would do this in the elderly. In this context, the fact that many
PCPs believe that they can, or are obliged to, detect HF based
on symptoms and signs alone, is of concern. A correct diagnosis
of HF requires objective evaluation of cardiac function. This is particularly important in the elderly, in whom the preponderance of
women and high prevalence of co-morbidities make a correct diagnosis based on symptoms and signs alone even more hazardous.
Our finding that I/G report practices that frequently deviate
from those recommended in guidelines is also of concern, as
many patients admitted to hospital with HF are cared for by
these specialists.
One obvious reason for why I/G report poor adherence to
guideline-recommended practice is that they have not read the relevant guidelines. And that is exactly what we found when we asked
physicians in our survey to report what influenced their practice.
That I/G do not read the guidelines has also been reported in a
single country survey.23 Moreover, the same authors reported
from a similar PCP survey that while most PCPs were aware of
the existence of a national guideline (SIGN), many had not read
it.24 This is a worrying finding that points to a failure of international and national societies to reach an important target audience. Guidelines on the management of HF have been written
mainly by C and published by cardiac societies and in cardiology
journals. Consequently, non-cardiologists may not have access to
the guidelines or may not feel that they are relevant to them.
Ideally, guidelines should be put together by an optimal mix of
C, I/G, PCP, and HF nurses, to assure their proper representation,
and should be disseminated by appropriate medical and nursing
organizations, and not just cardiac societies.
Although C may do better than I/G, they are not perfect in their
adherence to guideline-recommended practice (not surprising, as
only 32% C stated that guidelines had most influence on their
decisions in HF management). For example, only 58% C would
add spironolactone in a patient in sinus rhythm with worsening
symptoms of HF despite optimal treatment with an ACE-inhibitor,
b-blocker, and diuretic. In Romania, Italy, and Spain, this proportion was even lower. As SHAPE was carried out before
August 2003, the results of the CHARM25,26 trial did not affect
the SHAPE survey—in fact angiotensin receptor blockers only
scored 1% in this question. Approximately 20% of C in Romania,
Poland, and Italy stated that they would use digoxin instead,
whereas similar percentages in Spain and France would reduce
the dose of b-blocker. These findings highlight the need for continuing reinforcement of evidence-based practice through any possible means, e.g. registries aiming at improving outpatient HF care,
such as IMPROVE HF,27 targeted at C.
Limitations
In both surveys, there was a relatively low response rate, which
was expected based on experiences in earlier similar type of
surveys. Nevertheless, the target numbers were reached.
Whether those who responded were representative of the
overall physician’s group receiving a questionnaire would require
a sensitivity analysis, which was not possible in this survey.
Although a small response rate may introduce a bias, it is likely
Downloaded from http://eurheartj.oxfordjournals.org/ at Pennsylvania State University on March 5, 2014
Figure 1 Percentages of cardiologists (grey bars), internists/
geriatricians (black bars) and PCP (striped bars) who would prescribe target dosages of ACE-inhibitors, recommended in the
ESC guidelines on diagnosis and treatment of heart failure.
ACE, Angiotensin converting enzyme; LVEF, left ventricular ejection fraction; NL, The Netherlands; Fr, France; Sp, Spain; It, Italy;
Ro, Romania; UK, United Kingdom; Sw, Sweden; Pl, Poland; Ge,
Germany. *P , 0.01 vs. cardiologists.
W.J. Remme et al.
1749
Awareness and perception of heart failure
Table 6 Reasons for European PCPs not to prescribe an ACE-inhibitor or b-blocker
NL
Fr
Sp
It
Ro
UK
Sw
Pl
Ge
Total
285
7
297
2
298
3
454
8
377
1
278
12
300
1
328
3
2920
25
...............................................................................................................................................................................
When do you not prescribe an ACE-inhibitor? (tick all that apply)
Response rate (n)
Non-responders (n)
303
8
72
55*
87
56*
58
94
86
91
73
74
Cough (%)
BP,100 mmHg (%)
46
32
55
43
58
44
72
29
23*
49
27*
45
36
50
58
59
62
43
47
44
Creatinine.150 mmol/L (%)
40
52
35
25
28
56
57
46
41
42
Symptom free on diuretic (%)
Serum Na , 130 mmol/L (%)
41
12
11
25
25
16
18
10
15
9
24
33
25
32
16
17
40
16
24
19
0
4
4
3
7
2
2
3
4
3
When do you not prescribe a b-blocker? (tick all that apply)
Response rate (n)
274
Old age (%)
...............................................................................................................................................................................
266
282
299
458
338
274
299
322
2812
Non-responders (n)
37
26
17
2
4
40
16
2
9
153
Bradycardia (%)
COPD/asthma (%)
90
77
86
91
91
95
90
84
83
73
81
93
77
78
92
87
85
85
86
84
Unstable heart failure (%)
41
53
63
23
33
61
49
48
39
45
Mild symptoms on ACE-inhibitors þ diuretics (%)
Systolic BP , 100 mmHg (%)
44
22
56
33
42
29
33
16
17
33
47
21
41
26
9
40
35
28
35
28
Old age (%)
7
10
20
20
19
5
1
10
6
11
Cough (%)
Tachycardia (%)
4
1
3
1
3
1
4
0
8
1
7
2
5
1
6
3
9
0
6
1
P , 0.01 vs. other countries. ACE, angiotensin converting enzyme; BP, blood pressure; COPD, chronic obstructive pulmonary disease. Other abbreviations as in Table 1.
Table 7 Treatment strategies for heart failure by European PCPs
NL
Fr
Sp
It
Ro
UK
Sw
Pl
Ge
Total
270
20
264
37
321
10
2767
198
...............................................................................................................................................................................
With what medication do you start the treatment of heart failure in most patients? (tick one answer)
Response (n)
Non-responders (n)
285
26
275
17
285
14
267
34
432
30
368
10
ACE-I (%)
17
14
21
16
25
22
27
36
27
23
Diuretic (%)
ACE-Iþ diuretic (%)
57
22
54
28
42
35
11*
51
21*
28
63
14
42
25
16*
41
39
22
39
29
b-Blocker(%)
0
0
0
1
0
0
1
1
2
1
ACE-Iþb-Blockerþdiuretic (%)
Digoxin (%)
3
0
4
3
2
0
8
6
7
24*
0
0
4
0
9
4
8
2
5
5
Angiotensin-II antagonist (%)
1
0
0
0
0
0
0
0
0
0
...............................................................................................................................................................................
Which of the following medications do you prescribe when you observe a worsening of the symptoms, when the heart failure patient is already using an
optimal dose of diuretic and ACE-inhibitor? (tick all that apply)
Response (n)
Non-responders (n)
Add spironolacton (%)
307
291
298
299
4
52
1
43
1
44
2
41
459
3
16*
376
280
300
330
2940
2
59
10
50
1
60
1
42
25
44
Add digoxin (%)
31
29
31
48
49
22
23
60
44
38
Add b-Blocker (%)
Add calcium antagonist (%)
30
8
16
4
28
8
28
9
12
2
24
4
65*
0
50*
5
64*
8
34
5
Add angiotensin-II antagonist (%)
11
2
4
10
1
8
10
6
12
7
Send to specialist (%)
56
76
44
43
46
76
43
34
47
52
*P , 0.01 vs. other countries. ACE-I, angiotensin converting enzyme inhibitor. Other abbreviations as in Table 1.
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Renal artery stenosis (%)
1750
W.J. Remme et al.
that those physicians who responded were the ones more interested in and more aware of HF. Accordingly, the knowledge of
guideline-recommended approaches to the diagnosis and treatment of HF may be even less in the majority of physicians who
did not respond to the survey.
An interview-based survey in contrast to an actual-practice
study may not reflect what really happens with the patients in
physicians’ practices, but rather their perception of what they do
or should do in managing them. It is likely that collecting data
directly from patients could have further reduced the rate of
adherence to guidelines.
A further limitation is that there are no data on the typical age of
patients in different specialist practices nor in those of PCPs.
Patients are likely to be older in geriatric and possibly internist
and PCP practices than those seen by C. Age and greater
co-morbidity in the elderly may influence perception and practice
of different healthcare providers and their adherence to guidelines.
Indeed, in a previous survey PCPs did indicate that they felt comfortable treating older patients with significant co-morbidity on the
basis of a clinical diagnosis of HF.24 This may explain in part the
different diagnostic and therapeutic approaches of these physicians.
Conclusion
In conclusion, despite evidence-based guidelines, betweenphysician differences in the management of HF persist. In particular, the perceptions of the European PCP and I/G in aspects of HF,
including the use of diagnostic techniques and pivotal therapies
such as ACE-inhibitors and b-blockade, are not optimal. Consequently, there is significantly less uptake of recommended management strategies in their practices. As these non-cardiology
physicians care for many HF patients educational programmes to
increase their awareness and perception of HF are clearly
needed. In addition, research on methods to improve implementation of evidence-based medicine and the European guidelines
for management of HF in primary and non-cardiologist secondary
care should be encouraged. Education apart, integration in multidisciplinary groups, including specialized nurses and C, may
further increase the pivotal role of both the PCP and I/G in the
management of HF.
Study of Heart Failure Awareness
and Perception in Europe steering
committee
W.J. Remme (Chairman), A. Boccanelli, C. Cline, A. Cohen-Solal,
R. Dietz, F.D.R. Hobbs, J. Lopez Sendon, C. Macarie,
J. McMurray, B. Rauch, W. Ruzyllo, F. Zannad.
Study of Heart Failure Awareness
and Perception in Europe study
group
The following members of the SHAPE study group critically
reviewed the questionnaires:
France: J.M. Boivin, S. Briancon, A. Cohen-Solal, F. Zannad;
Germany: W. Assen, Ch. Zugck, R. Dietz, B. Rauch; Italy:
A. Boccanelli, G.F. Gensini, P. di Giulio, B. Guillaro, C. Opasisch,
M. Scherillo; The Netherlands: D. Grobbee, A. Hoes, T. Jaarsma,
W.J. Remme, D.J. van Veldhuisen; Poland: J. Grzybowski, M. Jedras,
W. Ruzyllo; Romania: I. Bruckner, R. Cristodorescu, D.E. Falnita,
C. Macarie, E. Petromaneantu; Spain: P. Conthe Gutierrez, J.M.
Lobos Bejarano, J. Lopez Sendon; Sweden: N. Göran Ahlin,
C. Cline, A. Iwarsson, G. Johansson; UK: F.D.R. Hobbs, M. Lye,
J. McMurray.
Downloaded from http://eurheartj.oxfordjournals.org/ at Pennsylvania State University on March 5, 2014
Figure 3 What cardiologists (grey bars) and internists/geriatricians (black bars) would do in a patient with worsening HF symptoms in sinus
rhythm and on optimal ACE-inhibitors, b-blockade (BB) and diuretics. ARB, angiotensin receptor blocker; CRT, cardiac resynchronization
therapy; iv, intravenous. Other abbreviations as in Figure 1. *P , 0.01 between specialists.
1751
Awareness and perception of heart failure
Conflict of interest: none declared.
Funding
The study was funded by an unrestricted grant from The Sticares Cardiovascular Research Foundation; Pfizer Inc.; F. Hoffmann-La Roche;
Servier International; Medtronic Foundation; Guidant Europe Nv/Sa;
GlaxoSmithKline; Abbott International; Chiesi Farmaceutici S.p.A.;
Merck KGaA.
References
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
Downloaded from http://eurheartj.oxfordjournals.org/ at Pennsylvania State University on March 5, 2014
1. The Task Force for the Diagnosis and Treatment of Chronic Heart
Failure of the European Society of Cardiology. Guidelines for the
diagnosis and treatment of chronic heart failure: executive
summary (update 2005). Eur Heart J 2005;26:1115 – 1140.
2. Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS,
Ganiats TG, Jessup M, Konstam MA, Mancini DM, Michl K,
Oates JA, Rahko PS, Silver MA, Stevenson LW, Yancy CW,
Antman EM, Smith SC, Adams CD, Anderson JL, Faxon DP,
Fuster V, Halperin JL, Hiratzka LF, Jacobs AK, Nishimura R,
Ornato JP, Page RL, Riegel B. ACC/AHA 2005 guidelines for the
diagnosis and management of chronic heart failure in the adult: a
report of the American College of Cardiology/American Heart
Association Task Force on practice guidelines. Circulation 2005;
112:e154– e235.
3. The Task Force on Heart Failure of the European Society of Cardiology. Guidelines for the diagnosis of heart failure. Eur Heart J
1995;16:741– 751.
4. The Task Force of the Working Group on Heart Failure of the
European Society of Cardiology. The treatment of heart failure.
Eur Heart J 1997;18:736– 753.
5. Remme WJ, Swedberg KS, on behalf of the Task Force for the
Diagnosis Treatment of Chronic Heart Failure, European Society
of Cardiology. Guidelines for the diagnosis and treatment of
chronic heart failure. Eur Heart J 2001;22:1527– 1560.
6. Komajda M, Lapuerta P, Hermans N, Gonzalez-Juanatey JR, van
Veldhuisen DJ, Erdmann E, Tavazzi L, Poole Wilson P, Le Pen C.
Adherence to guidelines is a predictor of outcome in chronic
heart failure: the MAHLER study. Eur Heart J 2005;26:1653 – 1659.
7. Komajda M, Follath F, Swedberg K, Cleland J, Aguilar JC,
Cohen-Solal A, Dietz R, Gavazzi A, Van Gilst WH, Hobbs R,
Korewicki J, Madeira HC, Moiseyev VS, Preda I, Widimsky J,
Freemantle N, Eastaugh J, Mason J, The Study Group of Diagnosis
of the Working Group on Heart Failure of the European Society of
Cardiology. The EuroHeart Failure Survey programme—a survey
on the quality of care among patients with heart failure in
Europe. Part 2: treatment. Eur Heart J 2003;24:464– 474.
8. Hobbs FDR, Jones MI, Allan TF, Wilson S, Tobias R. European
survey of primary care physician perceptions on heart failure diagnosis and management (Euro-HF). Eur Heart J 2000;21:
1877 – 1887.
9. Cleland JGF, Cohen-Solal A, Cosin Aguilar J, Dietz R, Eastaugh J,
Follath F, Freemantle N, Gavazzi A, Van Gilst WH, Hobbs FDR,
Korewicki J, Madeira HC, Preda I, Swedberg K, Widimsky J, for
the IMPROVEMENT of Heart Failure Committees Investigators,
the Study Group on Diagnosis of the Working Group on Heart
Failure of the European Society of Cardiology. Management of
heart failure in primary care (the IMPROVEMENT of Heart
Failure Programme): an international survey. Lancet 2002;360:
1631 – 1639.
10. Packer M, Bristow MR, Cohn JN, Colucci WS, Fowler MB,
Gilbert EM, Shusterman NH. The effect of carvedilol on morbidity
11.
and mortality in patients with chronic heart failure. N Engl J Med
1996;334:1349– 1355.
The Cardiac Insufficiency Bisoprolol Study II (CIBIS-II): a randomised trial. Lancet 1999;353:9 – 13.
Effect of metoprolol CR/XL in chronic heart failure: Metoprolol
CR/XL Randomised Intervention Trial in Congestive Heart
Failure (MERIT-HF). Lancet 1999;353:2001– 2007.
Pitt B, Zannad F, Remme WJ, Rody R, Castaigne A, Perez A,
Palensky J, Wittes J. The effect of spironolactone on morbidity
and mortality in patients with severe heart failure. N Engl J Med
1999;341:709– 717.
Bristow MR, Saxon LA, Boehmer J, Krueger S, Kass DA, De
Marco T, Carson P, DiCarlo L, DeMets D, White BG,
DeVries DW, Feldman AM. Cardiac resynchronisation therapy
with or without an implantable defibrillator in advanced chronic
heart failure. N Engl J Med 2004;350:2140– 2150.
Abraham WG, Fisher WG, Smith AL, Delurgio DB, Leon AR,
Loh E, Kocovic DZ, Packer M, Clavell AL, Hayes DL, Ellestad M,
Messenger J. Cardiac resynchronization in chronic heart failure.
N Engl J Med 2002;346:1845– 1853.
Remme WJ, Boccanelli A, Cline C, Cohen-Solal A, Dietz R, Hobbs R,
Keukelaar K, Lopez-Sendon J, Macarie C, McMurray J, Rauch B,
Ruzyllo W, Zannad F. Increasing awareness and perception of
heart failure in Europe and improving care—Rationale and design
of the SHAPE study. Cardiovasc Drugs Ther 2004;18:153 – 161.
Cohen Solal A, Desnos M, Delahaye F, Emeriau JP, Hanania G,
for the Myocardiopathy Heart Failure Working Group of the
French Society of Cardiology, The National College of General
Hospital Cardiologists, the French Geriatrics Society. A national
survey of heart failure in French hospitals. Eur Heart J 2000;21:
763 – 769.
Bellotti P, Badano LP, Acquarone N, Griffo R, Lo Pinto G,
Maggioni AP, Mattiauda C, Menardo G, Mombelloni P, for the
OSCUR investigators. Specialty-related differences in the epidemiology, clinical profile, management and outcome of patients hospitalized for heart failure. The OSCUR study. Eur Heart J 2001;22:
596 – 604.
Cleland JGF, Swedberg K, Follath F, Komajda M, Cohen-Solal A,
Aguilar JC, Dietz R, Gavazzi A, Hobbs R, Korewicki J,
Madeira HC, Moiseyev VS, Preda I, Van Gilst WH, Widimsky J,
Freemantle N, Eastaugh J, Mason J, for the Study Group on Diagnosis of the Working Group on Heart Failure of the European
Society of Cardiology Eur Heart Survey. The EuroHeart Failure
survey programme-a survey on the quality of care among patients
with heart failure in Europe. Part 1: patient characteristics and diagnosis. Eur Heart J 2003;24:442 – 463.
Hobbs FDR, Korewicki J, Cleland JGF, Eastaugh J, Freemantle N, on
behalf of the IMPROVEMENT Investigators. The diagnosis of heart
failure in European primary care: The IMPROVEMENT Programme survey of perception and practice. Eur J Heart Fail 2005;
7:768– 779.
Gottlieb SS, Fisher ML, Kjekshus J, Deedwania P, Gullestad L,
Vitovec J, Wikstrand J. Tolerability of beta-blocker initiation and
titration in the Metoprolol CR/XL Randomised Intervention Trial
in Congestive Heart Failure ( MERIT-HF). Circulation 2002;105:
1182 –1188.
Kotlyar E, Keoch AM, Macdonald PS, Arnold RH, McCaffrey DJ,
Glanville AR. Tolerability of carvedilol in patients with
heart
failure
and
concomitant
chronic
obstructive
pulmonary disease or asthma. J Heart Lung Transplant 2002;12:
1290 –1295.
1752
23. McKee SP, Leslie SJ, LeMaitre JP, Webb DJ, Denvir MA. Physicians
opinion on the implementation of the SIGN guideline for heart
failure. Scott Med J 2004;49:10 – 13.
24. Leslie SJ, McKee SP, Imray EA, Denvir MA. Management of chronic
heart failure: perceived needs of general practitioners in light of
the new general medical services contract. Postgrad Med J 2005;
81:321 – 326.
25. Pfeffer MA, Swedberg K, Granger CB, Held P, McMurray JJV,
Michelson EL, Olofsson B, Ostergren J, Yusuf S, for the CHARM
Investigators Committees. Effects of candesartan on mortality
and morbidity in patients with chronic heart failure: the
CHARM-overall programme. Lancet 2003;362:759– 766.
W.J. Remme et al.
26. McMurray JJV, Ostergren J, Swedberg K, Granger CB, Held P,
Michelson EL, Olofsson B, Yusuf S, Pfeffer MA, for the CHARM
Investigators Committees. Effects of candesartan in patients with
chronic heart failure and reduced left-ventricular systolic function
taking
angiotensin-converting
enzyme
inhibitors:
the
CHARM-Added trial. Lancet 2003;362:767– 771.
27. Fonarow GC, Yanct CW, Albert NM, Curtis AB, Stough WG,
Gheorghiade M, Heywood JT, Mehra M, O’Connor CM,
Reynolds D, Walsh MN. Improving the use of evidencebased heart failure therapies in the outpatient setting: the
IMPROVE HF performance improvement registry. Am Heart J
2007;154:12– 38.
doi:10.1093/eurheartj/ehn038
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. . . . . . . .publish-ahead-of-print
. . . . . . . . . . . . . . . . . . . . . . .22
. . . February
. . . . . . . . . .2008
.....
Pericardial cyst rupture mimicking acute aortic syndrome
Kazuhiro Nishigami1*, Touitsu Hirayama2, and Takihiro Kamio3
1
Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, 5-3-1 Chikami, Kumamoto 861-4193, Japan; 2Division of Cardiovascular Surgery, Saiseikai
Kumamoto Hospital Cardiovascular Center, Kumamoto, Japan; and 3Division of Pathology, Saiseikai Kumamoto Hospital Cardiovascular Center, Kumamoto, Japan
* Corresponding author. Tel: þ81 96 351 8000; Fax: þ81 96 351 8513, Email: [email protected]
A 75-year-old man presented with
chest pain and syncope. An urgent
contrast-enhanced computed tomography revealed double lumens in
the anterior mediastinum and bilateral pleural effusions, which were
suspected of type A acute aortic syndrome (Figure 1A). After the admission, the patient had sudden drop
in blood pressure and underwent
emergency surgery. Intraoperative
transesophageal
echocardiography
showed an echo like a flap in the
proximal aortic arch (Figure 1B).
Operative findings showed that the
aorta was intact although yellow
clear fluid was observed in the
anterior mediastinal and pericardial
spaces (Figure 1C). After the resection of pericardium, the patient’s
clinical status improved. Pathological
examinations of the pericardium
were compatible with pericardial
cyst rupture (Figure 1D).
Most pericardial cysts are asymptomatic. This case, however, presented
chest pain, syncope, and shock in
association with cardiac tamponade
following the rupture of a pericardial cyst, which mimicked acute aortic syndrome. Pericardial cyst rupture should be included in
the differential diagnosis of acute aortic syndrome.
Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2008. For permissions please email: [email protected].
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CLINICAL VIGNETTE