Diastolic heart failure

Diastolic heart failure is predominantly a disease of the elderly: at the age of 70 years, almost half of all patients with heart failure have diastolic heart failure. Hypertension and obesity are common underlying disorders in patients with diastolic heart failure. Patients with diastolic heart failure have an equal, or only slightly better, prognosis in terms of mortality compared to patients with systolic heart failure. Echocardiography can distinguish diastolic heart failure from systolic heart failure. Patients with heart failure and a normal ejection fraction almost certainly have a diastolic dysfunction. There is a lack of reliable data about the optimal medicinal treatment strategy for patients with diastolic heart failure. Angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, and (non-dihydropyridine) calcium antagonists have therapeutic potential. Digoxin may be contraindicated.     

Diastolic heart failure

The rhythmic contraction and relaxation of the heart supply the body with the appropriate amount of blood. If the pump function deteriorates, heart failure occurs. After a symptom-free period of varying length, the clinical case of decompensatio cardiaca develops. The pathophysiological basis of the disease is abnormal systolic and/or diastolic function. The pathophysiology and therapy of systolic heart failure is well-known, however, the consequence of impaired diastolic function has not been fully revealed. Both cardiogenic shock and pulmonary edema can be caused by acute left heart failure. The main difference between the two disorders is that while cardiogenic shock is caused by systolic dysfunction, pulmonary edema is the consequence of impaired diastolic function. The importance of diastolic dysfunction is highlighted by the fact that the disorder can be caused by the most frequent diseases (hypertension, diabetes mellitus, coronary heart disease, myocardiac infarction). Consequently, in case of risk factors, it is very important to consider the possibility of diastolic dysfunction and be aware of the diagnostic and therapeutic options.     

Quality of life in patients with heart failure: the perspective of primary health care

Objective

To measure and identify the dimensions and determinants of health-related quality of life (HRQoL) in patients with chronic heart failure.

Methods

We performed a cross-sectional study, in which HRQoL was measured with the short-form (SF)-36 and the Minnesota Living with Heart Failure Questionnaire (MLHFQ) in 544 clinically-stable patients with chronic heart failure managed by 97 primary care physicians.

Results

The mean age of the patients was 77.6 years (SD: 9.9) and was significantly higher in women. A total of 31.2% were in New York Heart Association (NYHA) grade III-IV and 88.6% had at least one chronic condition. In both questionnaires, physical dimensions scored worse than emotional dimensions. After adjustment was made for multiple regression, seven variables entered into one of the five models and explained between 22% and 36% of the variance.

Conclusions

HRQoL in patients with chronic heart failure is impaired across all domains. Being female and being in NYHA functional class III-IV, as well as other factors such as depression, osteoarticular disease, hospital admission, body mass index and age, were associated with poorer self-perceived HRQoL.     

Nutrition and the health care agenda: a primary care perspective

The current climate of prioritizing in the NHS brings into focus the debate surrounding efficient and effective management of conditions associated with the modern lifestyle. In any such debate, nutrition should be considered a primary issue as there is now international consensus regarding the optimum diet for the prevention of both coronary heart disease and cancer. Over recent years, government has stated that primary care is in an ideal setting to provide nutrition education to the public. However, we present the case that there currently is a mismatch between the attitude of the public, who appear willing to accept dietary advice from primary care professionals, and the reluctance on behalf of these professionals to fulfil this role. Dissatisfaction with the quality of nutrition education received by those working in primary care is often cited as a barrier to providing dietary advice to patients. With that in mind, we go on to discuss educational strategies that may motivate primary care staff to increase their involvement in providing dietary advice for their patients. The challenge to those involved in the delivery of nutrition training to primary care professionals is to convince them that dietary intervention is worthwhile and that they can make a positive contribution to dietary change within the current organization of primary care. Increasing motivation is an essential outcome of such training, along with providing the skills and knowledge to fulfil this role. The contribution which diet could make is significant and, in this time of questioning priorities, the role of nutrition needs to be put firmly on the health care agenda.     

Improvement of primary care for patients with chronic heart failure: a pilot study

Background  

Many patients with chronic heart failure (CHF) receive treatment in primary care, but data have shown that the quality of care for these patients needs to be improved. We aimed to evaluate the impact and feasibility of a programme for improving primary care for patients with CHF.     

Communication in heart failure: perspectives from older people and primary care professionals

The objective of this study was to explore the attitudes of older people and primary care professionals towards communication of diagnosis, prognosis and symptoms in heart failure. Forty-four interviews were conducted with people aged>60 years with heart failure (New York Heart Association III-IV) recruited from general practices in the UK. Ten focus groups were held with primary care professionals involved in heart failure management. Data were analysed thematically with the aid of the NUD*IST computer program. Participants reported problems with communication, including not being given enough information about their condition, or being given complex information that they did not understand. Many understood little about heart failure and the causes of, and ways to manage, their symptoms. Few participants had had discussions about the prognosis with any health professional, and this was confirmed in professional accounts. Difficulties with terminology were frequently reported: a diagnosis of 'heart failure' was rarely communicated to patients to avoid causing anxiety. Educational needs were identified by most primary care professionals in relation to heart failure management and specifically in relation to communication. In conclusion, communication was identified as being inadequate within primary care from both the patient and professional perspectives. These findings point to a need for an educational intervention tailored specifically to the need to improve the communication skills of primary care professionals in chronic heart failure.     

Community-oriented primary care: historical perspective

BACKGROUND: Community-oriented primary care (COPC) is a systematic approach to health care based upon principles derived from epidemiology, primary care, preventive medicine, and health promotion. We describe the development of COPC from an historical perspective. A critical assessment of current trends and implication for physician education and practice of COPC will be discussed in a companion article in the next issue of The Journal. METHODS: MEDLINE was searched using the key phrase "community-oriented primary care" Other sources of information included books and other documents. RESULTS AND CONCLUSIONS: In the 1950s, Sydney Kark showed dramatic positive changes in the health status of the population of Pholela, South Africa, using this approach. Similar approaches showed positive change in the health status of poor and underserved populations in the United States. The results were so impressive that the Institute of Medicine recommended widespread application of COPC in the United States. Successful COPC practices, however, have historically required considerable external funding from private and government sources. Thus, controversy about the feasibility of implementation of COPC in mainstream primary care practices developed. Schools of medicine and the discipline of family medicine have struggled to implement effective training in COPC within traditional medical school and residency structures. Yet, the societal need for recognition of and intervention in community health problems and coordination of community health resources continues.     

Ovulation induction with clomifene: a primary care perspective

Infertility affects one in seven couples during their lifetime. Approximately one-quarter of these will have an ovulatory disorder contributing to their inability to conceive. Ovulatory disorders represent the simplest form of infertility to treat, and where this is not a result of ovarian failure or poor ovarian reserve most women require ovulation induction with clomifene citrate (CC). This review aims to examine the role of CC in a general practice setting. CC is a simple, relatively safe, easily administered and well-tolerated efficacious drug. There is, however, a 10% risk of multiple births associated with its use. CC has been used in general practice for many years and continues to be used. Currently, guidelines do not describe its use in the general practice setting and the evidence for monitoring its use with mid-luteal progesterone estimation or ultrasound scanning is conflicting.     

Outpatient management of obesity: a primary care perspective

An estimated 64% of the adult population in the United States is either overweight or obese. Because obesity affects such a large percentage of the population and carries with it numerous health risks, it is essential that physicians treat obesity and encourage healthy-weight maintenance within the primary care setting. Effective weight management will require providing the appropriate physical environment for the overweight or obese patient, properly evaluating the impact of a patient's weight on health, evaluating a patient's readiness to change, setting appropriate weight-loss goals, and providing information and help about how to modify dietary and physical activity patterns. Achieving and maintaining weight loss is more likely to be successful when there is a physician-patient partnership where the physician provides support and motivation for the patient's efforts to initiate and maintain a healthy body weight.     

B-type natriuretic peptide: a review of its diagnostic,prognostic, and therapeutic monitoring value in heart failure for primary care physicians

BACKGROUND: Congestive heart failure is misdiagnosed clinically 50% to 75% of the time. B-type natriuretic peptide (BNP) concentrations have shown to be useful in the diagnosis of heart failure in addition to having prognostic and therapeutic monitoring value. Studies were evaluated for validity and potential value of BNP measurements for managing patients with heart failure. METHODS: A literature review using MEDLINE (1966 to present), CINAHL (1980 to present) and Evidence-Based Medicine Reviews was performed with the following key words: "cardiac neuro-hormone," "B-type natriuretic peptide," "congestive heart failure," and combination of the key terms. RESULTS AND CONCLUSIONS: A BNP level of 80 pg/mL is useful in diagnosing heart failure in symptomatic patients without a history of heart failure. BNP is not specific for any disease state, however, especially in patients with a history of heart failure or left ventricular dysfunction. BNP levels are potentially more useful when a baseline concentration is known for a patient, because BNP levels are proportional to the severity of heart failure. The role of BNP as a prognostic marker and for therapeutic monitoring is closely related. Whereas larger studies are needed to support further recommendations, a goal to maintain a BNP concentration of less than 100 pg/mL has shown to correlate with functional improvement in patients with heart failure and has tended to decrease clinical endpoints, such as cardiovascular death. Consequently, using BNP concentrations to monitor patients with heart failure and manage their medical therapy accordingly might improve overall morbidity and mortality.     

Monitoring quality in Israeli primary care: The primary care physicians' perspective

ABSTRACT: BACKGROUND: Since 2000, Israel has had a national program for ongoing monitoring of the quality of the primary care services provided by the country's four competing non-profit health plans. Previous research has demonstrated that quality of care has improved substantially since the program's inception and that the program enjoys wide support among health plan managers. However, prior to this study there were anecdotal and journalistic reports of opposition to the program among primary care physicians engaged in direct service delivery; these raised serious questions about the extent of support among physicians nationally. Goals To assess how Israeli primary care physicians experience and rate health plan efforts to track and improve the quality of care. METHOD: The study population consisted of primary care physicians employed by the health plans who have responsibility for the quality of care of a panel of adult patients. The study team randomly sampled 250 primary-care physicians from each of the four health plans. Of the 1,000 physicians sampled, 884 met the study criteria. Every physician could choose whether to participate in the survey by mail, e-mail, or telephone. The anonymous questionnaire was completed by 605 physicians - 69% of those eligible. The data were weighted to reflect differences in sampling and response rates across health plans. Main findings The vast majority of respondents (87%) felt that the monitoring of quality was important and two-thirds (66%) felt that the feedback and subsequent remedial interventions improved medical care to a great extent. Almost three-quarters (71%) supported continuation of the program in an unqualified manner. The physicians with the most positive attitudes to the program were over age 44, independent contract physicians, and either board-certified in internal medicine or without any board-certification (i.e., residents or general practitioners). At the same time, support for the program was widespread even among physicians who are young, board-certified in family medicine, and salaried. Many physicians also reported that various problems had emerged to a great or very great extent: a heavier workload (65%), over-competitiveness (60%), excessive managerial pressure (48%), and distraction from other clinical issues (35%). In addition, there was some criticism of the quality of the measures themselves. Respondents also identified approaches to addressing these problems. CONCLUSIONS: The findings provide perspective on the anecdotal reports of physician opposition to the monitoring program; they may well accurately reflect the views of the small number of physicians directly involved, but they do not reflect the views of primary care physicians as a whole, who are generally quite supportive of the program. At the same time, the study confirms the existence of several perceived problems. Some of these problems, such as excess managerial pressure, can probably best be addressed by the health plans themselves; while others, such as the need to refine the quality indicators, are probably best addressed at the national level. Cooperation between primary care physicians and health plan managers, which has been an essential component of the program's success thus far, can also play an important role in addressing the problems identified.     

Patients'' perspective in Chilean primary care: a questionnaire validation study

Objective. The aim of this study was to adapt and validate an instrumentfor assessing quality of care from the patients' perspectivein the context of Chilean primary care. Methods. The ‘Health Centre Assessment Questionnaire’ ismade up of six multiple-item scales and two single-item scalesaddressing eight key areas of primary care activity. A furthertwo single-item scales ask about the overall satisfaction andthe way in which the centre deals with patients' health issues.The adaptation process was developed according to methods describedin the specialized literature. The instrument was initiallypre-tested in a sample of 100 primary care patients. The validationwas carried out in 10 urban public primary healthcare centreswhere 2896 patients were invited to complete the questionnaire.The validity and reliability of the instrument was assessedusing standard psychometric techniques. Results. Ninety nine per cent (2870) of those approached completed thequestionnaire. It was acceptable to most of the patients asreflected by the high response rate, and a full range of possiblescores in most of the scales. Reliability was good as reflectedby high internal consistency and homogeneity. Validity was supportedby the confirmation of scaling assumptions, the moderate correlationsbetween multiple-item scales, and by the confirmation of our‘a priori’ hypothesis. Conclusions. The questionnaire could be a useful instrument for assessinga number of important dimensions in Chilean primary care. Itis acceptable, reliable and valid. Further work is requiredto evaluate its validity against external criteria and its test–retestreliability.