The management of heart failure in Sweden.

Heart failure is a major concern to health care providers in Sweden due to its increasing prevalence and the rising health care costs. Heart failure affects more than 160000 Swedes, approximately 2% of the population. The costs for the management of heart failure have been calculated to be approximately SEK 2.500 million (Euro 275 million) which is 2% of the total health care budget. Most heart failure patients are managed by primary care physicians but hospitalisation is common and heart failure is the most common cause for hospitalisation in patients over 65 years of age. National diagnostic and treatment guidelines are not completely adhered to. Echocardiography is performed in a little more than 30% of patients in primary care probably due to poor access. In hospitals echocardiography is more easily available and routinely used for diagnosis. Angiotensin-converting enzyme (ACE) inhibitors and beta-blockers appear to be under prescribed. Nurse-led heart failure clinics are being widely established in an attempt to curtail costs and improve management.

Health-related quality of life in elderly patients with heart failure.

OBJECTIVE: To assess health-related quality of life (HRQL) in elderly patients with congestive heart failure (CHF) and correlate these to clinical and demographic variables. PATIENTS AND METHODS: HRQL was evaluated in 191 patients with CHF, aged 65-84 years, using a self-administered questionnaire including the Nottingham Health Profile (NHP), Quality of Life Questionnaire in Heart Failure and Patients' Global Self-Assessment. RESULTS: HRQL was more impaired in women than to men (p < 0.05), New York Heart Association functional class correlated to HRQL (p < 0.01) and HRQL, as assessed by NHP, was impaired in CHF patients compared to a previously evaluated, age and sex matched, normal reference population. CONCLUSION: Measurement of HRQL in heart failure patients provides important information in addition to a clinical evaluation, and inclusion of HRQL assessments in clinical practice is feasible and warranted. Specific intervention should be aimed at improving HRQL in those most severely affected.

Non-compliance and knowledge of prescribed medication in elderly patients with heart failure.

AIMS: To determine the extent of non-compliance to prescribed medication in elderly patients with heart failure and to determine to what extent patients recall information given regarding their medication. METHODS AND RESULTS: Non-compliance and knowledge of prescribed medication was studied in 22 elderly heart failure patients [mean age 79 +/- 6 (range 70-97); 14 (64%) male], using in-depth interviews performed 30 days after having been prescribed medication. All patients received standardised verbal and written information regarding their medication. Only 12 (55%) patients could correctly name what medication had been prescribed, 11 (50%) were unable to state the prescribed doses and 14 (64%) could not account for when the medication was to be taken, i.e. at what time of day and when in relation to meals the medication was to be taken. In the overall assessment six (27%) patients were found non-compliant and 16 (73%) patients were considered as possibly being compliant with their prescribed medication. CONCLUSIONS: Non-compliance was common in elderly heart failure patients, as were shortcomings in patients knowledge regarding prescribed medication, despite efforts to give adequate information. There exists a need for alternative strategies to improve compliance in these patients.

Cost effective management programme for heart failure reduces hospitalisation.

OBJECTIVE: To study the effects of a management programme on hospitalisation and health care costs one year after admission for heart failure. DESIGN: Prospective, randomised trial. SETTING: University hospital with a primary catchment area of 250,000 inhabitants. PATIENTS: 190 patients (aged 65-84 years, 52.3% men) hospitalised because of heart failure. INTERVENTION: Two types of patient management were compared. The intervention group received education on heart failure and self management, with follow up at an easy access, nurse directed outpatient clinic for one year after discharge. The control group was managed according to routine clinical practice. MAIN OUTCOME MEASURES: Time to readmission, days in hospital, and health care costs during one year. RESULTS: The one year survival rate was 71.8% (n = 79) in the control group and 70.0% (n = 56) in the intervention group (NS). The mean time to readmission was longer in the intervention group than in the control group (141 (87) v 106 (101); p < 0.05) and number of days in hospital tended to be fewer (4.2 (7.8) v 8.2 (14.3); p = 0.07). There was a trend towards a mean annual reduction in health care costs per patient of US$1300 (US $1 = SEK 7.76) in the intervention group compared with costs in the controls (US$3594 v 2294; p = 0.07). CONCLUSIONS: A management programme for patients with heart failure discharged after hospitalisation reduces health care costs and the need for readmission.

Simplified echocardiography in the diagnosis of heart failure.

Echocardiography is essential in the diagnosis of heart failure, but insufficient resources limit its use. We compared swift (five minutes) simplified echocardiography, using elementary equipment, with standard echocardiography (45 minutes), using advanced equipment. Visual semi-quantification of cardiac dimensions, valvular stenosis, and left ventricular ejection fraction (LVEF) was performed in 100 consecutive patients with suspected or known heart failure. Agreement between simplified and standard echocardiography was 78-89% regarding semi-quantification of cardiac dimensions, and 95-98% for valvular stenosis (present/not present). Sensitivity and specificity for simplified echocardiography to identify patients with LVEF < 0.40 was 86 and 89%, respectively. Simplified echocardiography using elementary equipment could be an alternative to standard echocardiography in the diagnosis of heart failure. The cost and time saved by using simplified echocardiography allows for more patients to be examined, which should be weighed against its accuracy.

Prognostic significance of changes in left ventricular systolic function in elderly patients with congestive heart failure.

BACKGROUND AND DESIGN: The prognostic significance of changes in left ventricular systolic function over time is unknown in elderly patients with heart failure. We prospectively examined the relation between 1-year changes in left ventricular systolic function by echocardiographic determination of atrioventricular plane displacement (AVPD), and subsequent 2-year mortality and morbidity in elderly patients with heart failure. AVPD determination allows for left ventricular function to be adequately assessed even when image quality is poor, as is common in the elderly. METHODS: AVPD was measured at baseline and 1 year in 123 patients with heart failure (age 76.0 +/- 5.4 years). An AVPD change of 1 mm or more (corresponding to an ejection fraction change of 0.05) was considered significant. RESULTS: AVPD decreased in 26 patients (21%), increased in 46 (37%), and was unchanged in 51 (42%). During a 2-year follow-up (from the 1-year examination) mortality, total hospitalizations, and hospitalizations for heart failure (35% of all hospitalizations) did not differ significantly between the three groups. Patients (n = 80) with AVPD of 8.2 mm or less (corresponding to left ventricular ejection fraction of 0.40 or less) at the 1-year examination demonstrated a higher mortality than patients with AVPD greater than 8.2 mm (43.8 versus 23.3%; P = 0.031), and also had more hospitalizations and days in hospital due to heart failure (1.0 +/- 1.5 versus 0.4 +/- 0.8, P = 0.020 and 10.4 +/- 15.6 versus 4.6 +/- 10.6, P = 0.033, respectively). CONCLUSIONS: Left ventricular function was readily assessed in all patients by determination of AVPD. Our results indicate that single but not serial assessment of left ventricular systolic function by determination of AVPD is of value in assessing the prognosis in elderly patients with heart failure.