Heart: Gaping HF death disparity between specialist, general wards

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Heart failure (HF) patients admitted to general wards were twice as likely to die as those admitted to cardiology wards, according to a nationwide U.K. audit of the treatment of the condition, published online Jan. 17 in the journal Heart.

Women fared worse than men when it came to appropriate investigations and treatment, although death rates were similar.

John G.F. Cleland, MD, from the department of cardiology at the University of Hull in Kingston-upon-Hull, U.K., and colleagues drew their conclusions from a survey of the first 10 patients admitted each month with a primary diagnosis of HF to 86 hospitals across England and Wales between April 2008 and March 2009.

The primary outcome measures were rates of investigations, treatments and specialist management, length of hospital stay and mortality.

"The most striking finding from this analysis is the poor overall prognosis of patients who require admission to hospital with a primary diagnosis of heart failure," they wrote. "This is substantially worse than data from clinical trials suggest, which may reflect the exclusion of older, frail and multi-morbid patients and/or the survival benefit that appears to accrue from participating in clinical trials."

During the period of research, just over 6,000 patients, with an average age of 78, were admitted with the condition. Almost half of these were women.

Researchers found that almost half of the patients were managed in cardiology wards, and these patients tended to be younger and male, and were more likely to have echocardiography studies and to have left ventricular systolic dysfunction (LVSD) than those managed in general medical wards. However, the rates of co-morbidity including ischemic heart disease, atrial fibrillation (AF) and diabetes were similar.

The survey revealed that left ventricular ejection fraction (LVEF) was not recorded in 25 percent of patients, was less than 40 percent in 58 percent of all cases and greater than 40 percent in only 17 percent.

Patients with LVEF greater than 40 percent and those who had no reported LVEF had similar characteristics and were more likely to be women, older, managed on general medical wards and have AF and valve disease, but less likely to have had an MI compared with those with LVEF less than 40 percent. In addition, symptoms at presentation differed little by LVEF group.

The investigators found that mortality during the index admission was lowest (8 percent) among those with LVEF less than 40 percent, higher (11 percent) among those with LVEF greater than 40 percent, "perhaps due to the greater age of these patients," and highest among those without a recorded LVEF (18 percent).

Levels of natriuretic peptides, which are a much better barometer of likely outcome than LVEF, according to the authors, were only measured in 1 percent of patients, despite National Institute of Health and Clinical Excellence (NICE) recommendations.

Regarding death during the index admission, Cleland et al found that those admitted to general medical wards were twice as likely to die as those admitted to cardiology wards (HR, 2.5), even after taking into account other risk factors such as age, etiology, echocardiography, heart rhythm, sex and symptoms (HR, 1.9).

Regarding death following discharge, researchers found similar results. Patients discharged from general medicine wards were more likely to die than those discharged from cardiology wards (HR, 1.4), even after adjustment for risk factors (HR, 1.1).

In both the index admission and subsequent to discharge, younger patients and men fared better.

While most patients, in whom discharge drug treatment was recorded, were given the appropriate medicines, only half were prescribed beta-blockers. Men and younger patients were more likely to be given these drugs.

"Currently, hospital provision of care is suboptimal and the outcome of patents poor. The same rules that apply to suspected cancer should pertain to a disease with such a malign prognosis as heart failure," the authors concluded.

Researchers suggested that more attention could be paid to appropriate deployment of implantable cardiac defibrillator or cardiac resynchronization devices, although their analysis did not include devices.

They pointed to many new pharmacological treatments in development that are directed at improving myocardial function and to interventions directed at key co-morbidities such as anemia and renal impairment that may also improve outcomes.

"Just as for acute coronary syndromes, the development of heart failure units will improve the deployment of existing treatments and accelerate the identification of new ones," Cleland and colleagues concluded.

However, they emphasized that the most important finding "is that specialist care, both in the hospital and subsequent to discharge, is associated with better outcomes."