Primary Care Physicians Failing to Adhere to Heart Failure Guidelines - a Missed Opportunity to Save Lives? 50% of HF Patients Do Not Receive Optimal Treatment.

Business Editors/Health/Medical Writers

STRASBOURG, France--(BUSINESS WIRE)--June 23, 2003

Fifty percent of patients in Europe suffering from heart failure, a life-threatening and debilitating condition, do not receive optimal treatment. This is one of the results of a new European survey presented today at Heart Failure 2003 in Strasbourg.(1)

Undertaken by the Study Group on Heart Failure Awareness and Perception in Europe (SHAPE), in nearly 3,000 primary care physicians (PCPs) from nine European countries, the survey results show a lack of awareness of the appropriate management of this common and chronic condition.

KEY FINDINGS

Seventy-five percent of PCPs rely solely on signs and symptoms to diagnose heart failure despite strong recommendations from the European Society of Cardiology (ESC) guidelines to use tests which more accurately identify those patients with heart failure.

PCPs also fail to follow the European guidelines on treatment(1) in spite of the high mortality rate associated with heart failure. ESC guidelines recommend ACE-inhibitors as the first-line therapy in patients with heart failure and a beta blocker if patients remain symptomatic. Both treatments are considered mandatory by the ESC as they improve survival and morbidity. According to the results of the SHAPE survey, just over 50% of PCPs initiate heart failure treatment with an ACE-inhibitor. Instead patients are prescribed a diuretic, a symptomatic treatment for fluid retention, which has not been shown to improve survival. Moreover, 35% of PCPs think that ACE inhibitors can worsen heart failure and a staggering 86% think that beta blockers can worsen the condition. Consequently only 34% would add a beta blocker to ACE inhibition treatment. Also, 56% would not prescribe aldosterone antagonists, drugs shown to improve survival in heart failure. Importantly, even when PCPs do prescribe these therapies they are not prescribing the optimal dosage.

Most PCPs surveyed were able to identify the most common symptoms of heart failure, namely breathlessness on exertion (85%), nocturnal dyspnoea (70%), and swollen ankles (66%), although as few as 39% identified fatigue as a common symptom. These results are in contrast to a similar survey carried out by SHAPE, which investigated public awareness of heart failure. These data revealed that only 3% of the population could correctly identify heart failure from a description of typical signs and symptoms, although 85% claimed to have heard of the condition*.

The ESC guidelines state that diagnosis of heart failure should be confirmed by objective tests including echocardiography and using specific blood markers (natriuretic peptides). Indeed, the guidelines state that 'there is a poor relationship between symptoms and the severity of cardiac dysfunction and between symptoms and prognosis'(1), yet the SHAPE study shows a majority of European doctors are relying on subjective judgements based on signs and symptoms. Correct diagnosis is important for the management of heart failure as it is rapid killer with 40% of sufferers dying within one year of onset.(2)

Over 60% of PCPs surveyed knew that heart failure survival rates are bleaker than most cancers.(2,3,4) This contrasts with the public's perception where 67% wrongly believed heart failure patients live longer than cancer patients.*

Heart failure in Europe

In Europe up to 14 million people suffer from heart failure. The prevalence is, as in the US, on average 2% of the population.(5,6) The number of new cases reported each year is 2-3 individuals per 1,000 of the total population, rising by 10% in those aged over 80 years.(6) "Worryingly, these figures are set to rise with an increase in Europeans suffering from the main causes of heart failure and an ageing population" commented Professor Willem Remme, lead investigator and cardiologist at the Sticares Cardiovascular Research Institute, Rotterdam, the Netherlands.

"Across the whole of Europe we will see the numbers of people affected rapidly increase as risk factors of obesity, hypertension, high cholesterol and diabetes become more common. Yet awareness levels are surprisingly minimal. This will impact on individuals, families and healthcare resources with an increasing personal and financial burden."

"There is an urgent need to educate primary care physicians on the appropriate diagnosis and management of heart failure. This will have a positive impact on the prevention, survival and quality of life of heart failure patients.'' concluded Prof. Remme.

REFERENCES:

1. Remme WJ & Swedberg K. For the Task Force for the Diagnosis and Treatment of Chronic Heart Failure, European Society of Cardiology. Guidelines for the diagnosis and treatment of chronic heart failure. Eur Heart J 2001; 22: 1527-60.

2. Cowie MR et al. Survival of patients with a new diagnosis of heart failure: a population based study. Heart 2000; 83: 505-10.

3. Quinn M et al Cancer trends in England and Wales 1950-1999. Office for National statistics. 2001. The Stationary Office: London.

4. Stewart S et al. More 'malignant' than cancer? Five year survival following a first admission for heart failure. Euro J Heart Fail 2001; 3: 315-22.

5. Jessup M & Brozena S. Medical Progress : Heart Failure New Engl J Med 2003; 348 : 2007-2018

6. Cowie MR, Mosterd A, Wood DA et al. The Epidemiology of Heart Failure. European Heart Journal 1997; 18: 208-225

7. Mosterd A. Epidemiology of heart failure. The Epidemiology of Heart Failure 1997

8. Furberg CD, Pasty BM. Blood pressure and cardiovascular disease. In: Yusuf S, Cairns JA, Camm AJ, et al, eds. Evidence-Based Cardiology. 2nd ed. London, UK: BMJ Books; 2002.

9. Flather M et al. Long-term ACE-inhibition therapy in patients with heart failure or left ventricular dysfunction: a systematic overview of data from individuals patients. ACE-inhibitor Myocardial Infarction Collaborative Group. Lancet 2000; 355: 1575-81.

10. Pitt B, Zannad F, Remme WJ et al. for the Randomized Aldactone Evaluation Study Investigators. The effect of spironolactone on morbidity and mortality in patients with severe heart failure. N Engl J Med. 1999; 34: 709-717

11. Pitt B, Williams G, Remme W, et al. The EPHESUS Trial: eplenerone in patients with heart failure due to systolic dysfunction complicating acute myocardial infarction. Eplenerone Post-AMI Heart Failure Efficacy and Survival Study. Cardiovasc Drugs Ther. 2001; 15: 79-87

12. CIBIS Investigators and Committees. The Cardiac Insufficiency Bisoprolol Study II (CIBIS II). A randomized trial of beta-blockade in heart failure. Lancet. 1999; 353: 9-13

13. Packer M, Bristow MR, Cohn JN, et al. The effect of carvedilol on morbidity and mortality in patients with chronic heart failure. New Engl J Med. 1996; 334: 1349-1355

14. Packer M, Coats AJS, Fowler MB, et al. Effect of carvedilol on survival in severe chronic heart failure. New Engl J Med. 2001; 344: 1651-1658

15. The MERIT-HF Study Group. Effect of metoprolol CR/XL in chronic heart failure: metoprolol CR/XL randomized intervention trial in congestive HF (MERIT-HF). Lancet. 1999; 353: 2001-2007

16. Poole-Wilson PA, Swedberg K, Cleland JGF et al. Comparison of carvedilol and metoprolol on clinical outcomes in patients with chronic heart failure. Results of the Carvedilol Or Metoprolol European Trial (COMET). Lancet 2003; 361-to be published

17. Abraham WG, Fisher WG. Cardiac resynchronisation in chronic heart failure. NEJM 2002; 346: 1845-1853

18. Bristow MR, Saxon LA, Boehmer J et al for the COMPANION Investigators; ACC, Chicago 3/31/03

* The full results of the SHAPE survey of the general public will be released at the European Society of Cardiology meeting in Vienna, August 30 to September 4 2003

NOTES TO EDITORS:

Over the last decade important developments have occurred in heart failure management. New therapies have been investigated in large heart failure populations and have proven to be beneficial, significantly reducing mortality and improving patients' quality of life. Studies have demonstrated that angiotensin converting enzyme (ACE) inhibitors, beta blockers and aldosterone antagonists significantly reduce mortality and hospital admissions for heart failure.(9, 10,11,12,13,14,15,16) In case of intolerance to ACE inhibitors, angiotensin receptor blockers are used which have a comparable pharmacological profile. New non-pharmacological therapies such as cardiac resynchronisation therapy (CRT), with or without back-up defibrillation capabilities have demonstrated, in a number of clinical trials, to significantly improve quality of life(17), mortality and morbidity(18) over and above optimal pharmacological therapy in selected heart failure patients.

Heart failure is an extremely debilitating condition with a high hospitalisation rate. Heart failure admissions are rising and have increased by 60-130% in the last decade(7) and the burden of heart failure currently consumes around 2% of the total health care budget.(8)

SHAPE (the Study group on Heart failure Awareness and Perception in Europe) was initiated by an independent group of medical specialists.