Heart Failure in Outpatients: Comorbidities and Management by Different Specialists. The EPISERVE Study

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1 ORIGINAL ARTICLES Hert Filure in Outptients: Comoridities nd Mngement y Different Specilists. The EPISERVE Study José R. González-Juntey, Edurdo Alegrí Ezquerr, Vicente Bertoméu Mrtínez, c Pedro Conthe Gutiérrez, d An de Sntigo Nocito, e nd Ilonk Zsolt Frder f Servicio de Crdiologí, Hospitl Clínico Universitrio, Sntigo de Compostel, A Coruñ, Spin Deprtmento de Crdiologí y Cirugí Crdiovsculr, Clínic Universitri de Nvrr, Pmplon, Nvrr, Spin c Servicio de Crdiologí, Hospitl Universitrio Sn Jun de Alicnte, Sn Jun de Alicnte, Alicnte, Spin d Servicio de Medicin Intern, Hospitl Gregorio Mrñón, Mdrid, Spin e EAP Crmen Clzdo, Instituto Mdrileño de l Slud, Áre 3 de Atención Primri, Mdrid, Spin f Deprtmento Médico, Snofi-Aventis, S.A., Brcelon, Spin Introduction nd ojectives. The im of the EPISERVE study ws to investigte the clinicl chrcteristics of hert filure in outptients nd its dignostic nd therpeutic mngement y crdiology, internl medicine nd primry cre specilists. Methods. The study involved 507 physicins working in primry cre (n=181, 36%), crdiology (n=172, 34%) or internl medicine (n=154, 30%) who treted 2249 consecutive outptients with hert filure etween June nd Novemer Results. The prevlence of hert filure ws 2% in primry cre, 17% in crdiology nd 12% in internl medicine. Hypertension or coronry disese ws the cuse in more thn 80% of cses. The prevlence of comoridities ws high: tril firilltion, 46%; dietes, 38%; oesity, 64%; dyslipidemi, 60%; nemi, 27%; nd renl filure, 7%. In 40% of cses, systolic function ws preserved (ie, left ventriculr ejection frction 45%). Echocrdiogrphic nd coronry ngiogrphic studies were performed more frequently in ptients seen in crdiology nd in mle ptients. There were significnt differences etween men nd women in phrmcologic tretment involving et-lockers (55% vs 44%, respectively; P<.001), diuretics (88% vs 92%, respectively; P<.01), nd sttins (57% vs 47%, respectively; P<.001). Only 20% of ptients received the tretment recommended This study ws funded y n unrestricted grnt from Snofi-Aventis. The compny ws not involved in the design, dt nlysis, or writing of the mnuscript, or the decision to sumit it to Revist Espñol de Crdiologí. The dtse ws creted, mintined, nd nlyzed y Infocienci Clinicl Reserch. Both compnies deserve cknowledgement of their effective, professionl ssistnce. Correspondence: Prof. J.R. González Juntey. Servicio de Crdiologí. Hospitl Clínico Universitrio. Avd. Choupn, s/n Vidn. Sntigo de Compostel. A Coruñ. Spin. E-mil: jose.rmon.gonzlez.juntey@sergs.es Received Mrch 7, Accepted or puliction Mrch 3, y clinicl prctice guidelines. The fctors independently ssocited with pproprite tretment were eing treted in crdiology, hypercholesterolemi, ge, nd etiology. Conclusions. The vried pproches of different specilists, the smller effort put into dignosis nd therpy in women, nd the low percentge of ptients treted ccording to guidelines mke it essentil tht n eductionl nd multidisciplinry strtegy should e developed for mnging outptients with hert filure. Key words: Primry cre. Clinicl prctice guidelines. Hert filure. Internl medicine. Women. Insuficienci crdic en consults multoris: comoriliddes y ctuciones dignóstico-terpéutics por diferentes especilists. Estudio EPISERVE Introducción y ojetivos. El estudio EPISERVE pretendió crcterizr el perfil clínico y el mnejo dignóstico y terpéutico de l insuficienci crdic multori por especilists en crdiologí, medicin intern y tención primri. Métodos. Prticipron 507 profesionles de tención primri (n = 181; 36%), crdiologí (n = 172; 34%) y medicin intern (n = 154; 30%), que incluyeron consecutivmente pcientes multorios con insuficienci crdic entre junio y noviemre de Resultdos. L prevlenci de insuficienci crdic fue del 2% en tención primri, el 17% en crdiologí y el 12% en medicin intern. L hipertensión rteril y l crdioptí isquémic cusn más del 80% de los csos. L prevlenci de comorilidd fue elevd (firilción uriculr, 46%; dietes, 38%; oesidd, 64%; dislipemi, 60%; nemi, 27%; insuficienci renl, 7%). El 40% tení función sistólic conservd (frcción de eyección del ventrículo izquierdo 45%). Se disponí de más ecocrdiogrms y coronriogrfís de los pcientes tendidos por crdiologí y de los vrones. El trtmiento frmcológico mostró diferencis significtivs entre v- Rev Esp Crdiol. 2008;61(6):

2 rones y mujeres en l prescripción de loquedores et (el 55 frente l 44%; p < 0,001), diuréticos (el 88 frente l 92%; p < 0,01) e hipolipemintes (el 57 frente l 47%; p < 0,001). Sólo en el 20% se cumplín ls directrices gloles recomendds; ls vriles relcionds independientemente con l decución del trtmiento fueron tención en crdiologí, edd, hipercolesterolemi y etiologí. Conclusiones. Ls diferencis entre los diversos profesionles, el menor esfuerzo dignóstico y terpéutico en ls mujeres y el escso porcentje de pcientes trtdos según ls guís olign un plntemiento eductivo y multidisciplinrio en l tención multori de l insuficienci crdic. Plrs clve: Atención primri. Guís de práctic clínic. Insuficienci crdic. Medicin intern. Mujeres. ABBREVIATIONS AF: tril firilltion EF: ejection frction HT: hypertension NYHA: New York Hert Assocition INTRODUCTION Hert filure ffects 10% of individuls over the ge of 70 nd currently ccounts for round hospitl dmissions per yer in Spin, numer tht hs progressively incresed over the lst decde. Hert filure is the third most common cuse of mortlity in our country nd ws responsile for 4% of deths in men nd 8% in women in Ischemic hert disese nd hypertension (HT) re the min cuses of this condition. 2 Less common cuses include primry or toxic crdiomyopthy, vlvulr or congenitl lesions, right ventriculr dysfunction cused y lung disese, nd rrhythmi. Other importnt dditionl fctors relted to hert filure re dietes, 2,3 renl dysfunction, oesity, smoking, dyslipidemi, nd tril firilltion (AF). 2 Hert filure should e treted y joint collortion in different helth cre settings, nd should include the prticiption of hospitl nd community nursing professionls s well s physicins. 4-6 Most hert filure ptients re older individuls with severl concomitnt diseses, who re minly ttended y primry cre physicins on n outptient sis nd y internl medicine specilists or crdiologists when they re dmitted to hospitl. Severl studies pulished in recent yers hve rought to light vrious differences in the clinicl nd demogrphic profiles nd the dignostic nd therpeutic mngement of hert filure ptients depending on the specilty of the physicin responsile for their cre. 4,5,7-9 The EPISERVE study ws designed to nlyze these spects; in prticulr, to chrcterize the clinicl profile of ptients with hert filure nd the degree of complince with clinicl prctice guidelines in their dignosis nd tretment. METHODS Study Design nd Ptients Included The EPISERVE study ws designed s multicenter, cross-sectionl, uncontrolled, open, epidemiologic registry. The recruitment period spnned 5 months (June to Novemer 2005). A totl of 507 investigtors prticipted, distriuted over the entire territory of Spin, with the exception of the Rioj region, which did not prticipte. These physicins, who ttended ptients in primry cre (n=181; 46%), crdiology (n=172; 34%), nd internl medicine (n=154; 30%) outptient clinics, voluntrily greed to prticipte in the study fter receiving n invittion y mil (response rte, 16%). Following trining session, ech investigtor recorded dt from ll the ptients they sw until they hd compiled, in strict order of rrivl, the first 5 (different) ptients over 18 yers old nd dignosed with hert filure, s defined y the presence of t lest 1 of the following criteri: ) prior hospitliztion for hert filure; or ) dignosis of hert filure estlished y the presence of 2 mjor criteri or 1 mjor criterion nd 2 minor criteri ccording to the modified Frminghm system. 10 The only ptients excluded were those who refused to prticipte (<1%). The study ws pproved y the Reserch Committee of Hospitl Clínico de Sntigo de Compostel. All ptients signed consent form to prticipte fter eing informed of the expected risks nd enefits, nd the methods of the study. Dt Collection nd Dignostic Criteri Dt were compiled in computer dtse mnged y professionls who were not involved in collecting the informtion. Hert filure ws grded ccording to the stndrd NYHA clssifiction. 6 The min etiology ws estlished sed on the following criteri: ischemic disese when there ws documented history of myocrdil infrction nd presence of Q wves or evident left ventriculr dyskinesi on echocrdiogrphy, hypertensive disese when there ws long-term history of high lood pressure nd no other cuse of hert filure, vlve disese when there ws echocrdiogrphic evidence of significnt vlve involvement nd no other cuse of hert filure, cor pulmonle when there ws history of chronic lung disese nd no other cuse of hert filure, nd idiopthic crdiomyopthy when tht specific dignosis ws estlished on prior crdiologic study; 612 Rev Esp Crdiol. 2008;61(6):611-9

3 ll other etiologies were included under the heding Others. The dignosis of dietes ws sed on the criteri of the Americn Dietes Assocition. 11 The dignosis nd grding of hypertension were estlished ccording to the guidelines of the Sociedd Espñol de Crdiologí (Spnish Society of Crdiology). 12 Cererovsculr disese ws defined s stroke or trnsient ischemic ttck documented in the specilist s report, nd peripherl vsculr disese ws estlished y intermittent cludiction with n norml nklerchil index, presence of n dominl or thorcic neurysm, or history of peripherl revsculriztion. Atril firilltion (AF) ws considered to exist when there ws electrocrdiogrphic evidence of this condition, nd includes the proxysml, persistent, nd permnent types. Anlytic vriles corresponded to tests performed t the time of the study visit or within the previous 6 months. The dignosis of nemi ws sed on the stndrd criteri of the World Helth Orgniztion 13 : hemogloin <13 g/l in men nd <12 g/l in women. Renl filure ws estlished in ptients showing glomerulr filtrtion rtes <60 ml/min/1.73 m 2, estimted with the eqution presented in the MDRD study. 14 Dt from electrocrdiogrms, chest x-rys, nd echocrdiogrms cquired within the lst yer were included. Clinicl qulity control ws ssessed ttending to the guidelines of the Europen Society of Crdiology. 15 The following criteri were considered to indicte indequte clinicl control: hypontremi (<135 meq/l), hypoklemi (<3.5 meq/l), hyperklemi (>5.2 meq/l), nd renl filure (cretinine >1.7 mg/dl). The following were considered indequtely controlled risk fctors: lood pressure >130/80 mm Hg, 16 ody mss index >25, nd smoking (ny mount in the lst yer). Phrmcologicl tretment ws clssified s dequte if ptients received drugs tht re indicted, nd not ones tht re not indicted, in clinicl prctice guidelines 6,15 ccording to their NYHA functionl clss, nd indequte in the remining cses (therpies tht re not indicted or filure to receive drugs tht re indicted), s follows: et-lockers in ny functionl clss, providing tht the ptient did not hve sthm or severe chronic ostructive pulmonry disese; ngiotensin-converting-enzyme inhiitors in ll functionl clsses; diuretic gents in clsses III nd IV, s well s clss II when symptoms were present; spironolctone in functionl clss III nd IV in the sence of renl dysfunction nd hyperklemi; digitlis gents in ptients with AF nd those in functionl clsses III nd IV; nd dicoumrin in the presence of AF. Sttisticl Anlysis Vriles with continuous distriution (or quntittive vriles) re summrized y mesurement of the centrl tendency nd spred of the dt (men, stndrd devition, medin, nd 25th nd 75th percentiles) nd compred etween groups with the non-prmetric Mnn-Whitney or Kruskl-Wllis tests. Vriles with discrete distriution (or qulittive vriles) re shown y frequency tles nd compred with the χ 2 or Fisher exct test, when pproprite. In ll cses, 95% confidence intervls (CI) were pplied nd clculted over ech percentge. A P vlue less thn.05 ws considered significnt. Univrite logistic regression ws performed to detect fctors relted with dequcy of tretment. Adequte tretment ws considered the dependent vrile nd comorid conditions (dietes, dyslipidemi, oesity, smoking, coronry revsculriztion, cognitive deteriortion, renl filure, chronic ostructive pulmonry disese, nd cererl or peripherl vsculr disese), cuse of hert filure, demogrphic vriles, nd the helth cre setting were considered the explntory vriles. Vriles showing sttisticl significnce (P<.5) in the univrite nlysis were included in stepwise multivrite regression model. RESULTS Ptients Included The overll prevlence of hert filure ws 4.7% (2% in primry cre, 17% in crdiology, nd 12% in internl medicine). Among totl of 2534 ptients initilly identified, 285 (11%) were excluded ecuse they did not meet the criteri for hert filure (n=130) or were missing dt for the study (n=155). Among the 2249 ssessle ptients, 778 were seen y primry cre physicin, 777 y crdiologist, nd 694 y n internl medicine specilist. Men ge of the popultion ws 72 (10) yers nd 55% were men (54%, 61%, nd 51% of the primry cre, crdiology, nd internl medicine groups, respectively). The min clinicl chrcteristics of the ptients included re shown in Tle 1. Hypertension nd ischemic hert disese, lone or in comintion, were the cuse of more thn 80% of cses. There were numerous ssocited conditions: HT in 76% of cses, tril firilltion in 46%, nd dietes in 38%. Other crdiovsculr risk fctors included oesity (64%), hypercholesterolemi (50%), smoking (30%), nd hypertriglyceridemi (24%). The men glomerulr filtrtion rte ws 72.1 (84.2) ml/min. Dignostic Procedures The vilility of dignostic tests in the 3 outptient settings is presented in Tle 2. On chest rdiogrphy, ville in 86% of ptients, crdiomegly ws descried in 88% of ptients nd pulmonry congestion in 51%. Electrocrdiogrphy ws ville in 87% of ptients, Rev Esp Crdiol. 2008;61(6):

4 TABLE 1. Bseline Ptient Dt y Helth Cre Setting Primry Cre (n=778) Crdiology (n=777) Internl Medicine (n=694) Age, men (SD), y 76 (10) 66 (11) 75 (9) Mle sex, % Systolic rteril pressure, mm Hg Men (SD) 140 (18) 134 (22) 142 (24) Medin (P25;75) 140 (130;150) 131 (120;150) 140 (128;155) Distolic rteril pressure, mm Hg Men (SD) 80 (11) 78 (12) 78 (13) Medin (P25;75) 80 (70;88) 80 (70;85) 80 (70;85) Hert rte, (pm) Men (SD) 80 (14) 78 (16) 82 (16) Medin (P25;75) 79 (70;88) 75 (67;86) 80 (70;90) NYHA functionl clss, % I II III IV Anlytic dt Cretinine, men (SD), mg/dl 1.1 (0.4) 1.2 (0.4) 1.2 (0.5) Glucose, men (SD), mg/dl 116 (37) 115 (35) 125 (45) Hemogloin, men (SD), g/l 13.5 (1.6) 13.2 (1.6) 12.7 (1.8) Echocrdiogrm EF < EF > LVH Hospitl dmission for hert filure (lst yer) Men (SD) 1.3 (0.8) 1.5 (0.9) 1.5 (0.8) Medin (P25;75) 1 (1;2) 1 (1;2) 1 (1;2) Min etiology of hert filure, c % Ischemic Hypertensive Vlve disese Crdiomyopthy Cor pulmonle Others Comorid conditions, d % Hypertension Dietes Atril firilltion Permnent Proxysml/Persistent Peripherl vsculr disese Cererovsculr disese COPD Renl filure Anemi COPD indictes chronic ostructive pulmonry disese; EF, ejection frction; LVH, left ventriculr hypertrophy; NYHA, New York Hert Assocition; P25;75, 25th nd 75th percentiles; SD, stndrd devition. P<.05 with respect to the other 2 groups. Ptients with n echocrdiogrphy study within the pst yer. c Only shows the min etiology, considering s such the descending order of the Tle. d Cn e more thn 1 per ptient. with documenttion of left undle rnch lock in 18%, left ventriculr hypertrophy in 59%, nd permnent AF in 34%. Electrocrdiogrphy hd een crried out the previous yer in 61% of ll ptients, with noticely more tests in the group ttended y crdiologists. The EF ws <0.3 in 18%, 0.3 to 0.4 in 25%, 0.4 to 0.5 in 19%, nd >0.5 in 38%. Left ventriculr hypertrophy ws documented in 60%, nd the left tril dimeter ws 51.7 (9.4) mm. Crdic ctheteriztion ws performed in 31%, nd ws significntly more common in ptients ttended in crdiology. 614 Rev Esp Crdiol. 2008;61(6):611-9

5 TABLE 2. Dignostic Procedures Used y the Different Specilists Primry Cre (n=778) Crdiology (n=777) Internl Medicine (n=694) Chest x-ry Electrocrdiogrm Echocrdiogrm Ctheteriztion c Intervl since lst visit <1 Month Months Months Months >12 Months In the yer efore the visit nlyzed. P<.05 with respect to the other 2 groups. c Aville t ny stge of the condition. The vlues express percentges with respect to the totl numer of ptients ttended y ech type of professionl. Figure 1. Percentges of ptients who took specific tretments for hert filure distriuted ccording to the helth cre setting (n=2241). *P<.05 with respect to the other groups. ACEI indictes ngiotensin-converting enzyme inhiitors; ARB, ngiotensin II receptor locker; βb, et-lockers. Ptients, % * Diuretic ACEI ARB-II βb Primry Cre Crdiology Internl Medicine * There were no differences etween men nd women with regrd to vilility of electrocrdiogrphy nd chest rdiogrphy. In contrst, more echocrdiogrms were crried out in men thn women (63% vs 58%; P<.01), lthough differences were significnt only in primry cre (35% vs 28%). Crdic ctheteriztion ws lso performed in higher percentge of men thn women (35% vs 26%), with no sttisticl differences etween the 3 helth cre settings. Tretment Applied Almost ll ptients were under phrmcologicl tretment for hert filure: 98% were tking diuretics, 57% n ngiotensin-converting-enzyme inhiitor (ACEI), 47% n ngiotensin II receptor locker (ARB) (comintion of oth gents in 7%), nd 54%, etlocker. The rekdown of these drugs ccording to the prescriing professionl is shown in Figure 1. In ddition, 56% were tking lipid-lowering drugs, 21% clcium chnnel lockers, nd 35% digoxin, with no differences etween the 3 groups of specilists. Significnt differences were found etween sexes relted to the use of the vrious drug groups (men vs women): et-lockers, 55% versus 44% (P<.001), diuretics, 88% versus 92% (P<.01), nd lipid-lowering drugs, 57% versus 47% (P<.001). Differences in the use of et-lockers nd lipid-lowering drugs were significnt etween the 3 groups of professionls, wheres the use of diuretics ws only significnt in primry ttention. Loop diuretics were the most common in this group. Enlpril ws the most frequently prescried ACEI (57%) t men dose of 17 mg/dy, iresrtn ws the most frequently used ARB (57%) t men dose of 242 mg/dy, nd crvedilol ws the most commonly used et-locker (54%) t dose of 25 mg/dy. The specific gents from ech drug fmily nd the doses used to tret hert filure re summrized in Tle 3. Rev Esp Crdiol. 2008;61(6):

6 TABLE 3. Drugs nd Doses Used in Hert Filure Ptients Group Ptients, n(%) Drug Ptients, % c Dose, mg/d Men (SD) Medin (P25;75) ARB 1047 (47) Iresrtn (78) 300 (150;300) Vlsrtn (46) 160 (80;160) Losrtn (43) 50 (50;100) Cndesrtn (39) 16 (8;16) Others 7 Diuretics 2202 (98) Loop 77 Thizide 23 Spironolctone (29) 25 (25;25) ACEI 1279 (57) Enlpril (12) 20 (10;20) Rmipril 25 7 (4) 5 (5;10) Cptopril (55) 50 (25;75) Lisinopril 3 17 (8) 20 (10;20) Others 3 βb 1220 (54) Crvedilol (54) 12.5 (10;25) Bisoprolol 25 7 (10) 5 (5;10) Atenolol (36) 50 (50;50) Metoprolol 1 57 (41) 50 (25;100) Others 2 ACEI indictes ngiotensin-converting enzyme inhiitors; ARB, ngiotensin receptor lockers; βb, et-lockers; P25;75, 25th nd 75th percentiles; SD, stndrd devition. Among totl of 2249 ptients. Among the totl of ptients in this ctegory. TABLE 4. Percentges of Adequte Control of the Vrious Clinicl Fctors y the Different Specilists Vrile Primry Cre (n=778) Crdiology (n=777) Internl Medicine (n=694) Ntremi Klemi Cretinine Blood pressure Oesity Smoking Adequte drug tretment P<.01 with respect to the other 2 groups. P<.0001 with respect to the other 2 groups. Clinicl Control According to the Guidelines The percentges of ptients with optiml control of the clinicl fctors re shown in Tle 4. Only 20% of ptients received dequte tretment ccording to the current Europen nd Spnish guidelines, nd tretment ws significntly etter in ptients under the cre of crdiologists. Inclusion in the ctegory indequte tretment ws minly due to the indiction of diuretics in NYHA clss I nd filing to prescrie ACEI, etlockers, or spironolctone in NYHA clss >III. The proportion of ptients receiving nticogulnt tretment for AF ws 79% in primry cre, 86% in crdiology, nd 86% in internl medicine, with no significnt differences. The clinicl vriles relted to indequte tretment in the univrite nlysis were ge, dietes, dyslipidemi, smoking, ischemic hert disese, coronry revsculriztion, HT, nd peripherl vsculr disese, s well s the helth cre setting. In the multivrite nlysis (Tle 5), the only vriles independently relted to indequte tretment were the helth cre setting (crdiology vs internl medicine or primry cre), hypercholesterolemi, dvnced ge, nd etiology of hert filure (neither ischemic nor hypertensive). DISCUSSION The results of the EPISERVE study indicte considerle disprity in the clinicl nd therpeutic chrcteristics of hert filure ptients ttended in the 3 usul helth cre settings for this disese in Spin. To our knowledge, this is the first study of this nture conducted in Spin. In ddition to providing complete overview of hert filure, the findings of EPISERVE underline the need to mnge the disese s crosssectionl helth cre process tht includes ll the 616 Rev Esp Crdiol. 2008;61(6):611-9

7 TABLE 5. Determinnts of Adherence to Therpeutic Recommendtions in the Clinicl Prctice Guidelines Vriles OR (95% CI) Medicl setting Crdiology versus internl medicine 0.55 ( ) Primry cre versus internl medicine 0.97 ( ) Crdiology versus primry cre 0.61 ( ) Ischemic hert disese 1.88 ( ) Hypertension 2.16 ( ) Age c 1.01 ( ) Hypercholesterolemi 2 ( ) CI indictes confidence intervl; OR, odds rtio. Adjusted simultneously for ll the vriles on the Tle. Comprison etween the sence nd presence of the fctor nlyzed (vlues >1 indicte tht ttempts re eing mde to improve ptients who hve this fctor vs those tht do not). c Anlyzed s continuous vrile professionls involved (physicins nd nursing stff from vrious hospitl nd outptient specilties, s well s socil services), with the im of offering more integrted nd coordinted helth cre to ptients with this condition. Chrcteristics of Outptients With Hert Filure The EPISERVE study disclosed tht 17% of outptient crdiologic consulttions re for hert filure. Perhps for this reson there ws higher percentge of ischemic cuses thn hypertensive etiologies, when in most registries these 2 cuses tend to e present in similr proportions. 1,2,17,18 The men ge of our smple, 72 yers, concurs with popultion registries, s does the 55% of men, figure tht grdully decreses s the ge of the popultion nlyzed increses. It is likely tht ischemic etiology, which is more prevlent in the crdiology setting, led to slight increse in the percentge of middle-ged men. The comorid conditions tht stnd out include dietes (13%), HT (76%), nd AF (46%; permnent in 34%). The likely explntion is tht the dignosis of hert filure hd een mde more thn 1 yer erlier in 72% of ptients. The high prevlence of comorid conditions such s chronic ostructive pulmonry disese, cererl vsculr disese, nemi, nd renl filure is notle, nd these conditions were predictly more predominnt in ptients seen in the internl medicine setting. Conventionl crdiovsculr risk ws high in ptients in the EPISERVE registry: 64% were oese, vlue clerly higher thn in the generl popultion (round 24%). The distressing proportion of smokers (30%) is lso noteworthy. The BADAPIC 8 registry in Spin nd the EuroHert Survey 17 in Europe re mong most fr-reching studies focusing on hert filure, nd comprison of their results with those of EPISERVE would e of interest. The min difference etween the BADAPIC registry nd EPISERVE is the helth cre setting (specilized hert filure clinics in the former nd different settings in EPISERVE). This my e the reson why the men ge of the ptients included ws lower in BADAPIC, nd there ws higher percentge of men. Ischemic etiology predominted in oth studies, lmost certinly ecuse of the inevitle is of this fctor towrd crdiology. Functionl clss ws higher in the BADAPIC registry, wheres most of the ptients in EPISERVE (54%) were in functionl clss II. The ptients risk profile is similr in BADAPIC, EPISERVE, nd the EuroHert Survey. Dignostic Procedures It is logicl tht there would e higher frequency of consulttions in primry cre centers: round 90% of ptients were seen t intervls of <3 months in primry cre, wheres most of the crdiology ptients were seen out twice yer. The limited vilility of electrocrdiogrphy in primry cre ws noteworthy, despite the fct tht it is recommended test in clinicl prctice guidelines. 6,15 The smll percentge of centers equipped with this test hs een reported in other studies performed in outptient popultions. 5,7 In contrst, electrocrdiogrphy ws ville to most ptients seen in crdiology nd two-thirds of those ttended in the internl medicine setting. The lower frequency of indictions for electrocrdiogrphy in women is lso in keeping with the findings of other studies. In our series, this difference ws only significnt in ptients seen in primry cre. Severl fctors my hve influenced these results in ddition to differences in sex: more dvnced ge nd comorid conditions, s well s the helth cre setting hve een descried. It hs een proven tht electrocrdiogrphic testing during hospitliztion for decompensted hert filure or chronic hert filure is n independent determinnt of short- nd long-term survivl. 19,20 The presence of 38% of ptients with EF >0.5 stnds out in this study. This vlue is higher thn tht reported in the BADAPIC registry (32% of ptients with EF >0.45), ut is consistent with hert filure studies in settings other thn hospitl deprtments nd specilized hert filure units. 5,7,9,17,18 As in the other registries, our study documented left ventriculr hypertrophy in lmost 60% of ptients in whom echocrdiogrphy hd een performed, proly ecuse of the high prevlence of HT. 21 Tretment Applied Specific diets, prticulrly low-slt diets, were followed y more thn 80% of the totl series of ptients. However, high percentge of ptients did not engge in ny physicl exercise. This seems to indicte tht the helth Rev Esp Crdiol. 2008;61(6):

8 professionls cring for these individuls did not sufficiently emphsize the informtion out this vitl fctor. Nerly ll ptients were tking some type of phrmcologicl tretment: more thn 90% hd diuretics; more thn 80%, ACEI; nd 50%, et-lockers. The percentges of treted ptients were comprle to vlues reported in other registries, such s the BADAPIC 8 nd EuroHert Survey. 17 Although the doses of hert filurespecific drugs used were lower thn those recommended in the guidelines, 8,15 they re comprle to doses reported in other registries. 4,5,8,17 The percentge of ptients treted with et-lockers in crdiology ws clerly higher thn in the other 2 settings. This fct cnnot e ttriuted to the higher percentge of ptients with ischemic hert disese, since the clinicl prctice guidelines indicte the relevnce of this tretment in hert filure ptients in NYHA functionl clss II, regrdless of the etiology. 6,15 Another point of interest is the preference of primry cre physicins nd internl medicine specilists for ARB rther thn ACEI, which re prescried more often y crdiologists. 6,15 Consistent with other studies, 22 there were no significnt differences in the tretments pplied in reltion to the type of systolic or distolic dysfunction present. The sence of specific therpeutic recommendtions in the ltest clinicl prctice guidelines 6,15 for ptients with hert filure nd preserved systolic function is, without dout, determinnt fctor relted to this finding. However, the fct tht ACEI tretment showed no significnt fvorle effect in these ptients in the CHARM 23 nd PEP-CHF 24 studies indictes tht this prticulr type of hert filure my hve different response to tretment thn tht of ptients with hert filure nd decresed systolic function. Some uthors hve even suggested tht these my e 2 conditions with similr forms of clinicl presenttion, ut different pthogenesis. 18 A smller percentge of women received et-locker tretment thn men in ll 3 helth cre settings studied. This dtum, which is consistent in ll the registries, 5,8,17,18 my e relted to older ge nd lower prevlence of ischemic hert disese in women. In generl, the percentge of ptients receiving dequte tretment ccording to the recommendtions of the Prctice Guidelines of the Europen Society of Crdiology for the Dignosis nd Tretment of Chronic Hert Filure 15 ws higher mong ptients ttended in crdiology thn mong those seen in the primry cre or internl medicine setting (26% vs 18% nd 17%, respectively); other studies hve documented similr findings. 25 In contrst, lortory monitoring of sodium, potssium, hemogloin, nd cretinine ws stisfctory in the 3 settings. In ddition to smoking, the crdiovsculr risk fctor showing poorest control ws HT. This is seen in ll the studies investigting HT, whtever my e/regrdless of the concomitnt diseses nd helth cre settings. 5,7-9,12,16,17 Among other fctors, the higher prevlence of ischemic hert disese s the min determinnt of hert filure, lower ge of the ptients, nd lower prevlence of ssocited diseses my help explin why crdiologists showed etter complince with the guidelines. Nonetheless, tking into ccount the chnging clinicl sitution of hert filure, it does not suffice to prescrie specific therpeutic interventions with proven prognostic enefits. Close follow-up of ffected ptients is eqully importnt to void decompensted disese, gol tht cn only e chieved with integrtion nd coordintion mong the vrious helth cre settings involved. Without dout, this issue points to one of the min shortcomings of crdiovsculr medicine in Spin. Limittions of the Study Becuse the ptients included were seen in vrious settings (crdiology, internl medicine, nd primry cre), it ws not possile to ssess the clinicl chrcteristics of the popultion of ptients with hert filure in Spin; the study simply reflects the sttus of dily prctice in these specific specilties. Moreover, it cnnot e determined whether the type of smple chosen (consecutive rther thn rndom smpling) hs hd decisive influence on the results. The dignosis of hert filure ws not confirmed y ojective tests in ll cses (s occurs in most registries of this type); hence, ptients with other conditions my hve een included. The dt recorded in the registry were not sumitted to qulity control system; therefore, we cnnot exclude the possiility of selection is if inclusion ws not correltive, s the investigtors were clerly told it should e. The fct tht the prticipting investigtors were volunteers my hve introduced selection in the smples, lthough this would proly hve little relevnt impct. It does not seem likely tht the smll differences in the seline chrcteristics of the popultion ttended in the vrious settings would hve n influence on the dignostic nd tretment pproches pplied. Nonetheless, the greter comoridity of ptients seen y internl medicine nd primry cre physicins my hve hd n effect on the therpeutic strtegy used. Lstly, the smll percentge of physicins who ccepted the invittion to prticipte in the registry (16%) might hve introduced some degree of selection is in the ptient popultion included nd my hve hd some influence on the results. CONCLUSIONS Hert filure ptients comprise lrge volume of the totl outptient ctivity (17% in crdiology, 12% in internl medicine, nd 2% in primry cre). The recommendtions set down in clinicl prctice guidelines re followed for only 20% of these ptients. Crdiology specilists dhere more closely to these recommendtions 618 Rev Esp Crdiol. 2008;61(6):611-9

9 thn do primry cre nd internl medicine specilists. The dignostic nd therpeutic procedures indicted in clinicl prctice guidelines re prescried less often in women thn men. The EPISERVE study underlines the concept tht outptient hert filure cre should e performed in coordinted mnner with the prticiption of other professionls through multidisciplinry cre nd continuing eduction. REFERENCES 1. Rodríguez-Artlejo F, Bnegs JR, Gullr P. Epidemiologí de l insuficienci crdic. Rev Esp Crdiol. 2004;57: Knnel WB. Incidence nd epidemiology of hert filure. Hert Fil Rev. 2000;5: From AM, Leison CL, Bursi F, Redfield MM, Weston SA, Jcosen SJ, et l. Dietes in hert filure: prevlence nd impct on outcome in the popultion. Am J Med 2006;119: Lupón J, Prjón T, Urruti A, González B, Herreros J, Altimir S, et l. Reducción de los ingresos por insuficienci crdic en el primer ño de seguimiento en un unidd multidisciplinri. 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