Are the heart failure guidelines being implemented in primary care?

INTRODUCTION: Heart failure (HF) is an important public health concern in Brazil due to its high prevalence. Our objective was to study the performance of primary care physicians of the public health system in the management of heart failure in the city of Niterói, Rio de Janeiro state, comparing their practice to that recommended by the Brazilian Society of Cardiology (BSC) guidelines. METHODS: In a cross-sectional study, 167 patients aged over 18, with a primary diagnosis of heart failure (HF), were studied at the university hospital by questionnaire, physical exam, electrocardiogram (ECG), chest X-ray, and echocardiogram (echo) as the gold standard exam. RESULTS: HF was not confirmed by echo criteria in 56 cases (33.5%). Sixty-nine patients (40.6%) had not previously undergone any diagnostic exam. Mean age was 61 years (+/- 13.3) and 57% were women. The main divergences from the guidelines were underuse of echo (11.4%), angiotensin-converting enzyme inhibitors (ACEIs) (64.1%) and beta-blockers (BBs) (26.0%), and the most often prescribed of the latter were those without benefits in morbidity and mortality --propranolol (15.6%) and atenolol (6.6%). The association of ACEIs and BBs was used in 25% of patients. Diuretics were the most prescribed (64.7%) and spironolactone was used in 9.0% of cases. CONCLUSION: There is a significant divergence between primary practice and the BSC guidelines. In this setting, the limited availability of echo and of the recommended drugs, combined with a lack of information, restricts their use. A program to improve adherence to the guidelines and to an evidence-based approach, through continuous medical training, should be implemented to improve the quality of primary care.

Heart failure with preserved ejection fraction and systolic dysfunction in the community.

BACKGROUND: In developed countries, heart failure with preserved ejection fraction (HFpEF) is more prevalent than heart failure with reduced ejection fraction (HFrEF) in the community. However, it has not been completely established if this fact is also observed within our community. OBJECTIVE: To determine the most prevalent form of heart failure (HFpEF or HFrEF) and whether the prevalence of HFpEF is higher in the community. METHODS: This is a cross-sectional study conducted with patients clinically diagnosed with HF who were seen in community-based health care centers from January to December 2005. Echodopplercardiograms were performed for all patients. The form of HF was stratified according to the presence of abnormalities and the shortening fraction observed on the echodopplercardiogram. RESULTS: The study evaluated 170 patients (61.0 +/- 13.3 years of age), most of them women and elderly. HFpEF was the more prevalent form of HF (64.2%, p<0.001), affecting mostly elderly women (62%, p = 0.07), whereas the opposite condition, HFrEF, was observed mostly in elderly men (63.6%, p = 0.07). Patients with no HF represented one-third of the cases (27.6%). HFrEF patients had more lower-limb edema, coronary disease, diabetes, chronic renal failure, higher Boston scores and hospital readmissions. Use of alcoholic beverages and smoking were also more common among HFrEF patients. CONCLUSION: HFpEF is the most prevalent form of HF in the community especially among elderly women, whereas HFrEF affects mostly elderly men and is associated with greater clinical severity, main risk factors and no changes in lifestyle. Despite the signs and symptoms of HF, this condition was not confirmed for one-third of the cases.

Insuficiência cardíaca com fração de ejeção preservada e com disfunção sistólica na comunidade / Heart failure with preserved ejection fraction and systolic dysfunction in the community

FUNDAMENTO: Em países desenvolvidos, a insuficiência cardíaca com fração de ejeção preservada (ICFEP) é o modelo mais prevalente que a insuficiência cardíaca com disfunção sistólica (ICDS) na comunidade. No entanto, não está plenamente estabelecido se tal fato também é observado na nossa comunidade. OBJETIVO: Determinar o tipo mais prevalente de insuficiência cardíaca (ICFEP ou ICDS) e se a prevalência de ICFEP é elevada na comunidade. MÉTODOS: Estudo transversal de pacientes atendidos na comunidade com diagnóstico clínico de IC, de janeiro a dezembro de 2005. O ecodopplercardiograma foi realizado em todos os pacientes. O tipo de IC foi estratificado pela presença de anormalidades e pela fração de encurtamento ao ecodopplercardiograma. RESULTADOS: O estudo avaliou 170 pacientes (61,0±13,3 anos), a maioria mulheres e idosos. A ICFEP foi o tipo de IC mais prevalente (64,2 por cento, p<0,001) com tendência nas mulheres idosas (62 por cento, p=0,07), e o inverso na ICDS, nos homens idosos (63,6 por cento, p=0,07). Os pacientes sem IC representaram um terço dos casos (27,6 por cento). A ICDS apresentou mais edema de membros inferiores, doença coronariana, diabete, insuficiência renal crônica, re-internações e maior escore de Boston. O etilismo e o tabagismo estiveram mais presentes na ICDS. CONCLUSÃO: A ICFEP é o tipo de IC mais prevalente na comunidade, principalmente nas mulheres idosas, enquanto a ICDS, nos homens idosos, com maior gravidade clínica e acometimento dos principais fatores de risco e sem modificação nos hábitos de vida. Apesar dos sinais e dos sintomas de IC, em um terço dos casos a IC não foi confirmada.

BACKGROUND: In developed countries, heart failure with preserved ejection fraction (HFpEF) is more prevalent than heart failure with reduced ejection fraction (HFrEF) in the community. However, it has not been completely established if this fact is also observed within our community. OBJECTIVE: To determine the most prevalent form of heart failure (HFpEF or HFrEF) and whether the prevalence of HFpEF is higher in the community. METHODS: This is a cross-sectional study conducted with patients clinically diagnosed with HF who were seen in community-based health care centers from January to December 2005. Echodopplercardiograms were performed for all patients. The form of HF was stratified according to the presence of abnormalities and the shortening fraction observed on the echodopplercardiogram. RESULTS: The study evaluated 170 patients (61.0 ± 13.3 years of age), most of them women and elderly. HFpEF was the more prevalent form of HF (64.2 percent, p<0.001), affecting mostly elderly women (62 percent, p = 0.07), whereas the opposite condition, HFrEF, was observed mostly in elderly men (63.6 percent, p = 0.07). Patients with no HF represented one-third of the cases (27.6 percent). HFrEF patients had more lower-limb edema, coronary disease, diabetes, chronic renal failure, higher Boston scores and hospital readmissions. Use of alcoholic beverages and smoking were also more common among HFrEF patients. CONCLUSION: HFpEF is the most prevalent form of HF in the community especially among elderly women, whereas HFrEF affects mostly elderly men and is associated with greater clinical severity, main risk factors and no changes in lifestyle. Despite the signs and symptoms of HF, this condition was not confirmed for one-third of the cases.

The association between metabolic syndrome and its components and heart failure in patients referred to a primary care facility.

BACKGROUND: Metabolic syndrome (MS) is characterized by a collection of risk factors that are associated with elevated rates of cardiovascular events and the risk of developing heart failure (HF). In our field, the association of MS in stable chronic HF patients has not been established. OBJECTIVE: To determine the prevalence of MS in relation to gender and HF type in patients treated at a Primary Care Facility. METHODS: Between January 2005 and August 2006, 144 patients were included in a cross sectional study. An echocardiogram, using the modified criteria of the EPICA study, was performed to determine whether or not the patient had HF, and of which type. Statistical analysis was conducted using the software SAS System, version 6.04, and statistical significance was established as 5%. RESULTS: MS was observed in 111 patients (77%), of which 73 (66%) were females: odds ratio (OR) 0.195--(confidence interval--CI = 0.08 - 0.46) and p< 0.0001. HF was identified in 102 patients (71%) with a great correlation between females and the presence of MS: 51 patients (65%); OR 0.116 (CI = 0.36- 0.37) and p < 0.0001. Among the HF patients, 61 (42%) presented HF with preserved systolic function and 41 (29%) with systolic dysfunction; p = ns. HF with preserved systolic function was associated with the presence of MS in 53 (87%) of the 61 patients, p = 0.022. CONCLUSION: In our community, MS is closely related to HF with preserved systolic function and to the female gender.

Associação da síndrome metabólica e seus componentes na insuficiência cardíaca encaminhada da atenção primária / The association between metabolic syndrome and its components and heart failure in patients referred to a primary care facility

FUNDAMENTO: A síndrome metabólica (SM) caracteriza-se por um conjunto de fatores de risco que, quando presentes, se associam a elevadas taxas de eventos cardiovasculares, como também a risco de insuficiência cardíaca (IC). Em nosso meio, não está estabelecida a associação da SM nos pacientes portadores de IC crônica estável. OBJETIVO: Determinar, em pacientes encaminhados da Atenção Primária, a prevalência de SM, segundo o sexo e o tipo de IC. MÉTODOS: De janeiro de 2005 a agosto de 2006, 144 pacientes foram incluídos em um estudo transversal. A ecocardiografia, por meio de critérios modificados no estudo EPICA, foi utilizada para definir o tipo de IC, como também sua presença ou ausência. A análise estatística foi processada pelo software SAS® System, versão 6.04, sendo adotado o nível de significância de 5 por cento. RESULTADOS: SM foi observada em 111 pacientes (77 por cento), dos quais 73 (66 por cento) eram do sexo feminino (razão de chance [RC] de 0,195; intervalo de confiança = 0,08-0,46; p < 0,0001). IC foi identificada em 102 pacientes (71 por cento), com o sexo feminino apresentando grande correlação com a presença de SM: 51 pacientes (65 por cento) (RC de 0,116; intervalo de confiança = 0,36-0,37; p < 0,0001). Entre os portadores de IC, 61 pacientes (42 por cento) apresentavam IC com função sistólica preservada e 41 (29 por cento), IC com disfunção sistólica (p = ns). IC com função sistólica preservada foi associada à presença de SM em 53 (87 por cento) dos 61 pacientes (p = 0,022). CONCLUSÃO: A SM está fortemente associada à presença de IC com função sistólica preservada e ao sexo feminino em nossa comunidade.

BACKGROUND: Metabolic syndrome (MS) is characterized by a collection of risk factors that are associated with elevated rates of cardiovascular events and the risk of developing heart failure (HF). In our field, the association of MS in stable chronic HF patients has not been established. OBJECTIVE: To determine the prevalence of MS in relation to gender and HF type in patients treated at a Primary Care Facility. METHODS: Between January 2005 and August 2006, 144 patients were included in a cross sectional study. An echocardiogram, using the modified criteria of the EPICA study, was performed to determine whether or not the patient had HF, and of which type. Statistical analysis was conducted using the software SAS™ System, version 6.04, and statistical significance was established as 5 percent. RESULTS: MS was observed in 111 patients (77 percent), of which 73 (66 percent) were females: odds ratio (OR) 0.195 - (confidence interval - CI = 0.08 - 0.46) and p< 0.0001. HF was identified in 102 patients (71 percent) with a great correlation between females and the presence of MS: 51 patients (65 percent); OR 0.116 (CI = 0.36- 0.37) and p < 0.0001. Among the HF patients, 61 (42 percent) presented HF with preserved systolic function and 41 (29 percent) with systolic dysfunction; p = ns. HF with preserved systolic function was associated with the presence of MS in 53 (87 percent) of the 61 patients, p = 0.022. CONCLUSION: In our community, MS is closely related to HF with preserved systolic function and to the female gender.