Background: In July 2003 the National Institute of Clinical Excellence (NICE) issued guidelines on the management of congestive heart failure. We set out to assess the management of congestive heart failure in St. Luke's Hospital (SLH), Malta. Methods: The files of patients admitted to SLH during the month of January 2002 were retrieved. Eligible patients were those with a history of congestive heart failure. Patients who had passed away by the time of the audit or whose files were untraceable were excluded from the audit. Data from the file pertaining to that specific admission was entered in a preprepared data sheet. This includes demographic data about the patient, investigations performed to reach diagnosis and assess severity, pharmacological and non-pharmacological management of heart failure, and planned follow-up at time of discharge. Results: The management of 97 patients was assessed. All patients with a clinical diagnosis of congestive heart failure had an electrocardiogram, chest X-ray, urea, electrolytes and creatinine estimation and a full blood count. Regarding the other tests recommended by NICE, echocardiography was performed in 28% of patients, serum glucose was assayed in 87%, liver function tests in 36%, thyroid function tests in 24%, urinalysis in 13%, lipids in 8% and spirometry in none. Two per cent of patients had lifestyle modification advice documented in the file. Pharmacological treatment consisted of diuretics (98%), ACE inhibitors (71%), angiotensin II receptor blockers (4%), ß-blockers (9%), spironolactone (12%) and digoxin (25%). Conclusions: There is still scope for improvement in the management of congestive heart failure locally.peer-reviewe

Camilleri, Nicola

Sammut, David

Schembri, Stuart

English

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28 Malta Medical Journal    Volume 16   Issue 02   July 2004An Overview of the Managementof Congestive Heart Failure in MaltaOriginal ArticleStuart Schembri, David Sammut, Nicola CamilleriAbstractBackground: In July 2003 the National Institute ofClinical Excellence (NICE) issued guidelines on themanagement of congestive heart failure.  We set out to assessthe management of congestive heart failure in St. Luke’sHospital (SLH), Malta.Methods: The files of patients admitted to SLH duringthe month of January 2002 were retrieved.  Eligible patientswere those with a history of congestive heart failure.  Patientswho had passed away by the time of the audit or whose fileswere untraceable were excluded from the audit.  Data from thefile pertaining to that specific admission was entered in a pre-prepared data sheet.  This includes demographic data aboutthe patient, investigations performed to reach diagnosis andassess severity, pharmacological and non-pharmacologicalmanagement of heart failure, and planned follow-up at time ofdischarge.Results: The management of 97 patients was assessed.All patients with a clinical diagnosis of congestive heart failurehad an electrocardiogram, chest X-ray, urea, electrolytes andcreatinine estimation and a full blood count.  Regarding theother tests recommended by NICE, echocardiography wasperformed in 28% of patients, serum glucose was assayed in87%, liver function tests in 36%, thyroid function tests in 24%,urinalysis in 13%, lipids in 8% and spirometry in none. Twoper cent of patients had lifestyle modification advicedocumented in the file.  Pharmacological treatment consistedof diuretics (98%), ACE inhibitors (71%), angiotensin IIreceptor blockers (4%), ß-blockers (9%), spironolactone (12%)and digoxin (25%).Conclusions: There is still scope for improvement in themanagement of congestive heart failure locally.IntroductionChronic heart failure is known to be a major public healthproblem in industrialised countries with ageing populations.Its prognosis has been equated with that of the more commonmalignancies.  The management of heart failure requiresfrequent, prolonged, and costly admissions to hospital.1,2Despite this, studies have repeatedly shown that heartfailure is generally not managed optimally.3,4  Effectivetherapies are underprescribed and patients are often non-compliant.3,4  Lifestyle modifications such as exercise trainingand rehabilitation, advice on smoking and alcoholconsumption or vaccination against influenza andpneumococcal disease are often ignored.3,4 Should medicalcare improve, many hospital admissions would proveavoidable.3-5In July 2003 the National Institute of Clinical Excellence(NICE) issued guidelines6 on the management of congestiveheart failure. NICE is an independent organisation within theNHS responsible for providing national guidance on treatmentand care in the UK.  We set out to assess the management ofcongestive heart failure in St. Luke’s Hospital (SLH), Maltausing the NICE guidelines as the standard for ideal quality ofcare in order to identify areas of potential improvement.NICE guidelinesThe key recommendations from the NICE guidelines aresummarized in this section.Diagnosis• The basis for the historical diagnoses of heart failureshould be reviewed according to the algorithm outlinedin Figure 1.• Doppler 2D echocardiographic examination should beperformed to exclude significant valvular heart disease,assess the systolic (and diastolic) function of the (left)ventricle and detect intracardiac shunts.Treatment (Figure 2)• Lifestyle modification should be enforced in all patients.This should address exercise promotion, smokingcessation, modification of alcohol intake and vaccination.• All patients with heart failure due to left ventricularsystolic dysfunction should be considered for treatmentwith an ACE inhibitor.• Beta blockers licensed for use in heart failure should beinitiated in patients with heart failure due to leftventricular systolic dysfunction after diuretic and ACEStuart Schembri MD, MRCPDepartment of Medicine St. Luke’s HospitalGwardamangia MSD 07-MaltaEmail: stuart@keyworld.netDavid Sammut MD, MRCPDepartment of Medicine St. Luke’s HospitalGwardamangia MSD 07-MaltaEmail: dsammut@waldonet.net.mtNicola Camilleri MDDepartment of Medicine St. Luke’s HospitalGwardamangia  MSD 07-MaltaEmail: nicky_camilleri@waldonet.net.mtKeywordsCongestive heart failure, management audit.Malta Medical Journal    Volume 16   Issue 02   July 2004 29Figure 1: Recommendations for the diagnosis of heart failureFigure 2:  Algorithm for the pharmacological treatment of symptomatic heart failuredue to left ventricular systolic dysfunction30 Malta Medical Journal    Volume 16   Issue 02   July 2004inhibitor therapy regardless of whether symptoms persistor not.• Diuretics should be routinely used for the relief of congestivesymptoms and fluid retention in patients with heart failure.• Spironolactone should be considered in patients who remainmoderately to severely symptomatic despite optimaltherapy.• Digoxin should be considered if a patient in sinus rhythmremains symptomatic despite therapy with a diuretic, ACEinhibitor (or angiotensin II receptor antagonist) and beta-blocker or if the patient is in atrial fibrillation in which caseit is used as first-line therapy.Follow-up• All patients with chronic heart failure require monitoring.• This should consist of a clinical assessment of functionalcapacity, fluid status, cardiac rhythm, a review ofmedication, serum urea, electrolytes and creatinine.• Frequency of monitoring depends on clinical condition butshould not exceed 6 months.MethodsWe conducted a retrospective audit of the management ofheart failure at St. Luke’s Hospital.  The records of all patientsadmitted to the medical wards in January 2002 were obtainedand those patients with a primary or secondary diagnosis ofheart failure were considered eligible for the purposes of theaudit.  Patients who had passed away by the time of the auditand those patients whose files were untraceable were excludedfrom the analysis.  Data from the files was entered in a pre-prepared data sheet (Figure 3).  Demographic data about thepatient, investigations performed to reach the diagnosis andassess severity, management of heart failure (bothpharmacological and non-pharmacological), and plannedfollow-up were recorded on the data sheet.Four hundred and thirty-nine case notes were requested ofwhich 72 could not be traced, 184 patients had died and 183case notes were found, of which 97 satisfied the criteria andwere entered into the audit.The diagnosis of congestive heart failure depended on eitherpresentation to Accident and Emergency Department with signsand symptoms suggestive of heart failure or a note in the medicalhistory listing congestive heart failure as a concurrent medicalcondition.A total of 97 patients were included in the study and theircharacteristics are shown in Table 1.The male-to-female ratio was close to 1:1 with 47 males and50 females.  As expected the females had a slightly higher meanage at 77 years compared to a mean age of 74 years for males.We looked at the incidence of the following co-morbidconditions: ischaemic heart disease (35 patients), hypertension(46 patients), diabetes mellitus (38 patients), chronicobstructive pulmonary disease (30 patients), chronic renalfailure (27 patients), peripheral vascular disease (4 patients),anaemia (2 patients) and gout (2 patients). There were 9smokers, 29 ex-smokers and 59 non-smokers.The aim of the audit was to assess the management ofpatients suffering from congestive heart failure in SLH duringadmission and follow-up.  We compared current practice withthe NICE recommendations.Figure 3: Form used for data collectionTable 1: Baseline characteristics of the patients (n=97)Characteristic NumberGenderMales 47 Age Range: 54 - 91 years  Mean: 74 yearsFemales 50  Age Range: 57 - 93 years  Mean: 77 yearsSmoking StatusSmokers 9Ex-smokers 29Non-smokers 59Co-morbid conditionsIschaemic heart disease 35Hypertension 46Diabetes mellitus 38Chronic obstructive-pulmonary disease 30Chronic renal failure 27Peripheral vascular disease 4Anaemia 2Gout 2Malta Medical Journal    Volume 16   Issue 02   July 2004 31Results and DiscussionDiagnosisThe guidelines suggest that when a diagnosis of heart failureis considered, a 12-lead ECG and / or natriuretic peptides shouldbe measured.  When one or both are abnormal, the diagnosisshould be confirmed by echocardiography.  Furthermore,diseases that may present in a similar fashion should be excludedby the tests shown in Figure 1.Most patients did not have the full range of investigationssuggested by NICE (Table 2).In fact although electrocardiography, a chest radiograph andassays for urea, electrolytes, creatinine and a full blood countwere performed in all patients, the use of other tests was ratherlow.  Eighty-seven percent of patients had a blood glucoseassessment, 36% liver function tests, 24% thyroid function, 13%urine analysis, 8% lipid profile and none had spirometry.Echocardiography, for the purpose of these guidelines servesas a diagnostic tool to confirm the diagnosis of chronic heartfailure and exclude other pathologies.  The guidelines onlyspecify the need for a single echocardiogram; follow-up studiesare not mentioned.  The number of patients who had ever hadan echocardiogram for any reason was 28% with the dates oftests going back up to 11 years previously.B-type natriuretic peptide is a neurohormone secreted fromthe cardiac ventricles in response to volume expansion andpressure overload.  It has been shown to be highly sensitive as atest to rule out chronic heart failure - a normal assay being veryunlikely even in a patient with asymptomatic heart failure.  Thetest is not available at St. Luke’s Hospital so none of our patientshad this assayed.TreatmentA diagrammatic representation of the algorithm for thepharmacological treatment of symptomatic heart failure isshown in Figure 2.Our audit showed that only 2% of patients had lifestylemodification advice documented in the case notes.  While somedegree of lifestyle modification advice is possibly given to mostpatients, this analysis shows failure to deliver documentedstandardised recommendations in 98% of patients.Ninety-eight per cent of patients were treated with diuretics,bumetanide being the most common. The dose ranged from 1mgto 10mg daily in divided doses.  Two patients were on frusemide,1 on bendrofluazide and 4 patients were having both bumetanideand bendrofluazide.All chronic heart failure patients should be on an ACEinhibitor.  The only absolute contra-indications are anuria orangioedema with previous exposure to the drug, bilateral renalartery stenosis, pregnancy and cardiogenic shock.  In our patientcohort 70 were on an ACE inhibitor.  Out of the remaining 28patients, 2 were on an angiotension II receptor blocker, 2 hadelevated creatinine levels below 200 µmol/L, 1 had peripheralvascular disease which may raise concerns on renal arterystenosis and 3 had creatinine levels above 200 µmol/L but below300µmol/L.  The guidelines advise caution in the use of ACEinhibitors in patients with serum creatinine above 200µmol/L.They recommend monitoring electrolytes and creatinine withdiscontinuation only if potassium rises above 6mmol/L orcreatinine increases by more than 100% or above 350µmol/L.Seventy-four per cent of patients treated for heart failurewere given either an ACE inhibitor or an angiotensin II receptorblocker.  Twenty-five patients were not given either treatment,with 6 possible contra-indications as outlined above (in onlyone case was there documentation in the case notes).  It wasnot clear why the other 19 patients were not being given thistreatment.Enalapril was used in 64 of the 70 patients treated with ACEinhibitors. NICE recommends that this should be started off ata dose of 2.5 mg bd, which is then doubled every second weekuntil the maximum tolerated dose or the target dose of10-20 mg bd is reached.  Figure 4 shows the dosage distributionof enalapril in our patient cohort.  It is evident that the dosesused are less than those recommended with the mean dose being9mg dly, less than half the target dose.  Only 6 patients are beingtreated at target doses.  In spite of the low doses being used,dosage was increased in only 9% of outpatient visits.Table 2: Percentage of patients undergoingrecommended testsInvestigation % of patientsEchocardiography 28BNP* 0ECG 100Chest X-Ray 100Urea, electrolytes and creatinine 100Full blood count 100Plasma Glucose 87Liver Function 36Thyroid Function 24Urinalysis 13Lipids 8Spirometry 0 *BNP is B-type natriuretic peptide, a marker of ventriculardysfunction.  Assay currently not available at SLHFigure 4: Dosage distribution of enalaprilin study populationDaily dose enalapril (mg)Number of patients32 Malta Medical Journal    Volume 16   Issue 02   July 2004Beta blockers are recommended in all patients with heartfailure due to left ventricular systolic dysfunction after diureticand ACE inhibitor therapy regardless of whether symptomspersist or not.Three large mortality trials have clearly demonstratedfavourable outcomes with beta-blocker use in patients with heartfailure using carvedilol, metoprolol and bisoprolol.7,8,9  At thetime of submission, only carvedilol and bisoprolol were licensedin the UK for use in heart failure.Our audit showed that only 9 patients were on beta-blockertherapy (7 on carvedilol, 1 on atenolol and 1 on sotalol).  In ourstudy population there were 30 patients with chronic obstructivepulmonary disease or asthma and 4 patients suffering fromperipheral vascular disease.  Beta-blockers are contra-indicatedin reversible airways disease although a cardio-selective beta-blocker can be used with adequate caution.  Peripheral vasculardisease is not a contra-indication to prescription of a beta-blocker.  Excluding pulmonary disease patients, 13% of eligiblepatients were on a beta-blocker.  In none of the other cases wasdocumentation found in the patients’ notes of a reason as towhy beta blockade was not started.NICE recommends that patients already on a beta-blockerfor some other reason be kept on the same medication.  Due tothe initial deterioration in cardiac function after starting beta-blockade, these drugs should be commenced when the clinicalcondition is stable.Spironolactone has been shown to increase life expectancyin moderate to severe heart failure.10  Twelve patients were onspironolactone.  Unfortunately it proved very difficult todetermine baseline severity of heart failure from the notes asNYHA class is infrequently documented.  We therefore cannotcomment on whether this drug is being under-utilised.Follow-upNICE suggest that all patients with heart failure should haveregular follow-up visits.  The range between visits should dependon the clinical status of the patient, though the maximuminterval should be of 6 months.  In our audit we found that 55%of patients had outpatient follow up visits.  The interval betweenappointments ranged from 1 to 12 months.  Due to frequentusage of vague terms such as, “first available MOP”, it was notpossible to determine mean interval between visits.Conclusions and RecommendationsThe analysis performed by us has a number of limitations.It is a retrospective analysis of the management of patients priorto the publication of the guidelines that we used as a goldstandard. Most of the evidence on which the guidelines werebased had been previously published, and the use of certaindrugs already formed part of daily medical practice althoughtheir optimal use may have been less widespread.At St. Luke’s Hospital there are logistic difficulties inrequesting certain tests such as echocardiograms,notwithstanding the fact that 300 echocardiograms areperformed every month.  This may not necessarily mean thatthe clinician is unacquainted with their importance.Patients who had passed away by the time of the study wereexcluded as it would be problematic to analyse the adequacy oftheir follow-up.  On the other hand this introduces a bias in ourstudy population since it is difficult to determine whether  sub-optimal treatment could have contributed to their death.Despite the limitations of our audit, which was aimed atgetting an overview of current management practice, we suggestthat the diagnosis of heart failure should be reassessed in allpatients, their notes should be checked and any investigationsthat need to be done should be carried out as per NICEguidelines. One investigation that should be more frequentlyused is echocardiography which is currently being done in lessthan one third of patients.While 75% of patients are on ACE inhibitors or angiotensinII receptor antagonists, target doses should be attained andmore emphasis needs to be placed on incrementing medicationat each outpatient visit with a view to reaching maximal tolerateddoses.  After numerous trials showing the beneficial effects ofbeta-blockers, their use in the local setting is definitely sub-optimal.Follow-up should be more consistent and frequent.  Theinvolvement of primary care physicians could serve to cut downon hospital out-patient waiting lists and help to optimise patientcare.References1. McMurray JJ, Stewart S. Epidemiology, aetiology, and prognosisof heart failure. Heart 2000; 83: 596-602.2. Stewart S, MacIntyre K, Hole DJ, Capewell S, McMurray JJ. More‘malignant’ than cancer? Five-year survival following a firstadmission for heart failure. Eur J Heart Fail 2001; 3: 315-322.3. Ashton CM. Care of patients with failing hearts: evidence forfailures in clinical practice and health services research J GenIntern Med 1999; 14: 138-140.4. Chin MH, Goldman L. Factors contributing to the hospitalizationof patients with congestive heart failure. Am J Public Health 1997;87: 643-648.5. Blue L, Lang E, McMurray JV, Davie AP, McDonagh TA, MurdochDR, et al. Randomised controlled trial of specialist nurseintervention in heart failure. BMJ 2001; 323: 715-7186. Chronic heart failure: Management of chronic heart failure inadults in primary and secondary care. National Institute ofClinical Excellence issued July 2003. www.nice.org.uk7. Packer M, Coats AJ, Fowler MB, et al. Effect of carvedilol onsurvival in severe chronic heart failure. N Engl J Med2001;344(22):1651-8.8. Effect of metoprolol CR/XL in chronic heart failure: MetoprololCR/XL Randomised Intervention Trial in Congestive HeartFailure (MERIT-HF). Lancet 1999;353(9169):2001-7.9. The Cardiac Insufficiency Bisoprolol Study II (CIBIS-II): arandomised trial. Lancet 1999;353(9146):9-13.10. Pitt B, Zannad F, Remme WJ, et al. The effect of spironolactoneon morbidity and mortality in patients with severe heart failure.Randomized Aldactone Evaluation Study Investigators. N Engl JMed 1999;341(10):709-17.This paper was presented at the 5th Maltese Medical School Conference, December 2003and was awarded the Prize for Best Oral presentation in Medicine by the Association of Physicians of Malta.

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Care of patients with failing hearts: evidence for failures in clinical practice and health services research

Chronic heart failure: Management of chronic heart failure in adults in primary and secondary care.

Effect of carvedilol on survival in severe chronic heart failure.

Effect of metoprolol CR/XL in chronic heart failure: Metoprolol CR/XL Randomised Intervention Trial in Congestive Heart Failure (MERIT-HF).

Factors contributing to the hospitalization of patients with congestive heart failure.

More ‘malignant’ than cancer? Five-year survival following a first admission for heart failure.

Randomised controlled trial of specialist nurse intervention in heart failure. BMJ

The Cardiac Insufficiency Bisoprolol Study II (CIBIS-II): a randomised trial.

The effect of spironolactone on morbidity and mortality in patients with severe heart failure. Randomized Aldactone Evaluation Study Investigators.

An overview of the management of Congestive Heart Failure in Malta

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An overview of the management of Congestive Heart Failure in Malta

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