Complexities of managing heart failure in primary careDr. Nuria Farré - Barcelona, Spain and dr. Miguel Angel Muñoz - Barcelona, Spain
General practitioners from about 20 European countries travelled to Barcelona to attend the Annual EPCCS CV Summit for Primary Care. In addition to the lively discussions and interaction between primary care physicians of different corners of Europe, an important objective of this summit is to produce guidance documents specifically aimed at primary care. Sessions were set up in such a way that not only the current evidence on a subject was reviewed, but that specific considerations for primary care were discussed and challenges and gaps in the evidence were identified. These sessions focused on diabetes and vascular care, managing lipids, hypertension and heart failure. Based on the sessions, EPCCS guidance documents will be written.
Dr. Nuria Farré (Barcelona, Spain) started her presentation Managing complex heart failure: a specialist view of the primary/secondary interface by saying that the number of older patients with heart failure (HF) will be increased by 2050. The incidence of HF is currently 4.2% and the prevalence at the population level 1.1%. Under the age of 75 years, HF is more prevalent among men, whereas above 75 years, HF is more common among women. The prognosis is bad with a mortality rate of 10% for patients who were never hospitalised and almost 25% for patients with recent hospitalisations. In 2013, 7.1% of the healthcare budget was used for the care of HF patients in the Catalonian population, spent on hospitalisation, pharmacy and primary care.
Several departments at the hospital, primary care, skilled nursing centres, pharmacies and social workers take care of HF patients. But the care is not optimally coordinated. A study in Catalunya revealed for example that of 34% of patients who were hospitalised, the primary caretaker did not know about it. The mortality rate within 90 days was higher in this group compared to patients whose primary caretaker knew about the hospitalisation . In general, a mortality rate of 33.1% was observed within 90 days after hospitalisation, therefore it is important to coordinate care for HF patients. Working alone is not an option.
The effectiveness of interventions for the transition of care to primary care after hospitalisation of HF patients was studied in a meta-analysis, which showed that disease management by nurse programmes were associated with better survival than education alone. Therefore, implementation of an integrated hospital-primary care programme is recommended. There is a higher risk of re-hospitalisation the first 30-90 days after discharge and close follow-up can decrease hospitalisation. Unfortunately, not everyone can go to a hospital; this might for instance be a problem in rural areas. Telemedicine might be a solution. Monitoring of biometrics (heart rate, blood pressure, weight) and symptoms on a daily basis in addition to a HF program resulted in a reduction of CV endpoints compared to HF program alone. Although there is more contact with nurses, this programme was cost-effective as it reduced re-hospitalization. Dr. Farré emphasised that a new care system should not be expected to work from day 1; often effects only develop later.
Dr. Miguel Angel Muñoz (Barcelona, Spain) explained his view on the role of the GP in the management of HF patients in his presentation Managing heart failure in primary care: The GP perspective. This entails the whole spectrum from diagnosis to taking care of patients until the end stages. He discussed the progression of HF: from risk factors to changes in the cellular pathophysiology, ventricular remodelling to eventually ventricular dysfunction.
Risk factors for HF can be split into major ones (CAD, hypertension, diabetes, obesity, valvular heart disease) and minor ones (smoking, dyslipidaemia, CKD). A study on control of CV risk factors showed that control of blood pressure, HDL and BMI were significantly associated with HF hospitalisation, suggesting that primary care plays a relevant role in HF prevention.
In a publication on the perception of HF among different types of healthcare specialists showed that GPs diagnose patients with HF based on symptoms and signs. These are documented in the 2016 ESC Guidelines for diagnosis and treatment of HF. Variability in diagnosis can exist because not every GP knows/follows guideline recommendations, and/or because the GP has (no) access to BNP determination, and feasibility of obtaining an echocardiogram in reasonable length of time varies. This variability in diagnosis may result in overdiagnosis of HF by one-third of primary care takers. The prognosis of HF patients with missing or unknown LVEF is similar to those with reduced LVEF, but people with unknown EF may have a higher risk of hospitalisation or death than patients with HFrEF.
In follow-up, self-care and educational measures are important in primary care to encourage patients to stay as healthy as possible. Muñoz explained, using a schematic flowchart, what to do in a situation of decompensation. An intervention study is undertaken to develop a model based on clinical variables, to predict short-term hospitalisation or mortality in primary care as a consequence of HF decompensation. Under certain conditions, such as worsening of symptoms despite optimal treatment, renal function worsening, more than three hospital admissions in one year, he refers his patients to the cardiologist.
HF is a progressive and lethal disease and end of life care should be considered in patients with HF when pump failure is near. At the end of life, quality of life of patients and taking care of families are important issues. Although the HADES study revealed factors associated with mortality after 6 months or 1 year that can be used to predict which patients will most likely die soon, many questions remain.
Also read our EPCCS Guidance Document on heart failure, based on a previous session on heart failure at an annual EPCSS Scientific Meeting.