Catching the missed opportunities in heart failure.

The coalescence of heart failure study and treatment into a legitimate subspecialty has largely been fueled by the shared interests of cardiologists who study and treat advanced heart failure in tertiary centers. The growth of this subspecialty over the past decade has been accompanied by an exponential growth in treatment options for patients with heart failure and apparent success in reducing the morbidity and mortality associated with this condition (1). The past decade has also seen a striking increase in the number of patients with heart failure (2) and emergence of heart failure into a bona fide public health problem. Heart failure viewed from a tertiary treatment center is different from heart failure viewed from a public health or epidemiologic perspective. In tertiary centers patients are typically middle-aged, male, and have severe systolic dysfunction and little independent comorbidity. Heart failure specialists in referral centers are surprised and skeptical when epidemiologists tell us that the “typical” patient with heart failure is older than 75 years, female, and has relatively preserved systolic dysfunction and several other conditions such as diabetes and chronic obstructive lung disease. Some have tried to reconcile these differences by suggesting that the epidemiologic view of heart failure is distorted by overdiagnosis of heart failure in the community. The report of underdiagnosis by Akosah et al in the present issue of Journal of Cardiac Failure (3) therefore should reduce our surprise and skepticism about the contemporary nature of heart failure. This view of heart failure in the community is a valuable expansion of our concept of this disease. Akosah et al (3) reviewed the records of 225 patients discharged from a single community hospital who had an admission complaint of shortness of breath and who did not have a discharge diagnosis of heart failure. Of these patients 51 met Framingham criteria for the presence of heart failure and had a previous or subsequent demonstration of impaired left ventricular systolic function. The patients were less likely to have evidence of venous congestion than a group of patients in whom the diagnosis of heart failure was made successfully. These 51 patients had a 1-year rate of death or cardiac readmission statistically not different from that of a similar group of 240 patients in whom the diagnosis of heart failure was made. The study has important limitations. Data on which the Framingham criteria determinations were made came from many physicians. The investigators were unable to track admissions to other facilities. We do not know how treatment differed between these 2 groups. Despite these limitations, this report tells us that failure to diagnose heart failure is not a rare event. As we attempt to improve the care of patients with heart failure, we will need to add this problem of misdiagnosis to the problem of undertreatment. Failure to prescribe angiotensin-converting enzyme (ACE) inhibitors to all eligible heart failure patients is well documented, most recently in a nationwide Health Care Financing Administration study showing that state rates of ACE inhibitor prescription in eligible patients vary from 47% to 91% with a median rate of 69% (4). The Health Care Financing Administration has made improvement of these rates a major target for its quality improvement efforts. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) will soon use a similar measure of the quality of heart failure care From the Division of Cardiology, Denver Health Medical Center, University of Colorado Health Sciences Center, and Colorado Foundation for Medical Care, Denver, CO. Reprint requests: Edward P. Havranek, MD, Denver Health Medical Center #0960, 777 Bannock St, Denver, CO 80204-4507. Copyright © 2001 by Churchill Livingstone 1071-9164/01/0703-0005$35.00/0 doi:10.1054/jcaf.2001.27661 Journal of Cardiac Failure Vol. 7 No. 3 2001