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Awareness and perception of heart failure among European cardiologists, internists, geriatricians, and primary care physicians

Willem J. Remme, John J.V. McMurray, F.D. Richard Hobbs, Alain Cohen-Solal, José Lopez-Sendon, Alessandro Boccanelli, Faiez Zannad, Bernhard Rauch, Karen Keukelaar, Cezar Macarie, Witold Ruzyllo, Charles Cline
DOI: http://dx.doi.org/10.1093/eurheartj/ehn196 First published online: 27 May 2008

Abstract

Aims To assess awareness of heart failure (HF) management recommendations in Europe among cardiologists (C), internists and geriatricians (I/G), and primary care physicians (PCPs).

Methods and results The Study group on HF Awareness and Perception in Europe (SHAPE) surveyed randomly selected C (2041), I/G (1881), and PCP (2965) in France, Germany, Italy, the Netherlands, Poland, Romania, Spain, Sweden, and the UK. Each physician completed a 32-item questionnaire about the diagnosis and treatment of HF (left ventricular ejection fraction <40%). This report provides an analysis of HF awareness among C, I/G, and PCP. Seventy-one per cent I/G and 92% C use echocardiography, and 43% I/G and 82% C use echo-Doppler as a routine diagnostic test (both P < 0.0001). In contrast, 75% PCP use signs and symptoms to diagnose HF. Fewer I/G would use an angiotensin-converting enzyme (ACE)-inhibitor in >90% of their patients (64 vs. 82% C, P < 0.0001), whereas only 47% PCP would routinely prescribe an ACE-inhibitor. Worsening HF was considered a risk of ACE-inhibitor therapy by 35% PCP. I/G and PCP consistently do not prescribe target ACE-inhibitor doses (P < 0.0001 vs. C). Only 39% I/G would use a β-blocker in >50% of their patients (vs. 73% C, P < 0.0001). Also, only 5% PCP would always, and 35% often, prescribe a β-blocker and reach target doses in only 7–29%. Moreover, 34% PCP and 26% I/G vs. 11% C (P < 0.0001) do not start a β-blocker in patients with mild HF, who are already on an ACE-inhibitor and are on diuretic. In mild, stable HF, 39% PCP and 18% I/G would only prescribe diuretics, vs. 7% C (P < 0.0001). In patients with worsening HF in sinus rhythm and on an optimal ACE-inhibitor, β-blockade and diuretics, significantly more C would add spironolactone, but I/G would more often add digoxin.

Conclusion Although each physician group lacks complete adherence to guideline-recommended management strategies, these are used significantly less well by I, G, and PCPs, indicating the need for education of these essential healthcare providers.

Keywords
  • Heart failure
  • Awareness
  • Perception
  • Europe
  • Guidelines
  • Diagnosis
  • Treatment
  • Advice
  • Cardiologists
  • Internists
  • Geriatricians
  • Primary care physicians
  • ACE inhibition
  • β-Blockade
  • Aldosterone antagonists
  • Diuretics
  • Echocardiography
  • Heart failure nurses

Introduction

Two decades of controlled clinical trials have led to significant developments in drug and device treatment of heart failure (HF). When and how to apply these evidence-based treatments is detailed in several international guidelines.1,2 These guidelines also provide recommendations on diagnostic investigations and non-pharmacological treatments, including lifestyle advice, exercise, and surgery. Despite the availability of guidelines for more than a decade in Europe,1,35 HF management still appears to be suboptimal, possibly because physicians do not implement guideline recommendations. Whereas surveys have been carried out among cardiologists (C) in Europe,6 the picture among internists (I) and geriatricians (G) is not clear, and a detailed comparison between different specialists involved in HF care across Europe is lacking.7 In contrast, previous surveys have clearly indicated that adherence to guideline-recommended practice is low among primary care physicians (PCPs).8,9 However, the most recent and largest of these studies, IMPROVEMENT-HF,9 started in 1999, around the time evidence was emerging of the benefit of β-blockers and spironolactone in addition to ACE-inhibitors to treat HF.1013 Subsequently, other non-pharmacological treatments have been shown to reduce morbidity and mortality.14,15 Since these surveys, new national and international evidence-based guidelines have been published and widely disseminated. It is appropriate therefore to re-examine contemporary understanding of and attitudes to HF treatment in Europe.

The Study of HF Awareness and Perception in Europe (SHAPE) was designed to evaluate HF awareness among the general public and physicians involved in HF care. Here, the findings among C, I, G, and PCP are compared across nine European countries.

Methods

The rationale and design of the SHAPE study have been previously published in detail.16 The study was carried out in France, Germany, Italy, the Netherlands, Poland, Romania, Spain, Sweden, and the UK, and aimed at including at least 300 PCP, 150 C, and 150 I/G combined per country. For the PCP survey, a questionnaire containing 33 questions was developed to gather PCPs’ knowledge of HF (including prevalence, aetiology, new diagnostic and therapeutic developments, and healthcare costs); the diagnostic procedures and treatments carried out by the PCPs in their own practices, their referral patterns for diagnostic procedures and specialist care; and the type of practice and number of patients in each primary care practice. The questionnaires sent to C, I, and G (in combination referred to as specialists) contained 32 questions covering epidemiology, aetiology, and diagnostic and therapeutic strategies in congestive heart failure (CHF), as well as some demographic and practice-related questions. In both questionnaires, treatment questions were specifically about CHF with a reduced left ventricular ejection fraction (<40%). Where applicable, respondents were requested to indicate their order of preference for a diagnostic or therapeutic intervention and the questions were based on the available European guidelines on diagnosis and treatment of HF. The questions were ordered so as not to influence answers. The questionnaires were piloted for reliability and validity, and final versions translated into each country's native language and checked for content and accuracy of translation by native-speaking physicians of the relevant countries and members of the SHAPE study group.

Questionnaires were coded by country and individual physician to preserve anonymity.

Primary care physician survey

A total of 18 000 PCPs were randomly selected from the nine countries. The minimum number of completed questionnaires required per country was set at 300. Assuming a 15% response rate, questionnaires were mailed to 2000 PCPs per country, randomly selected using a pre-specified algorithm from lists of all PCPs received from the respective PCP organizations in each country. In countries where the response was <15% in the first round, a second mailing was done following a second random selection from the remaining PCPs, the number based on the response rate from the first mailing.

In Italy, Romania, Sweden, and the UK, one mailing was sufficient. In the other countries, between 2139 (Spain) and 3881 (Germany) questionnaires were sent out in total.

Specialist survey

To achieve a minimum of 300 completed questionnaires per country (at least 150 C and 150 I/G), the questionnaire was sent to all specialists, in countries with ≤1500 specialists (using computer lists containing the names, specialization and addresses of each specialist), whereas in other countries a random selection of 1500 physicians (50% C and 50% I/G) was made using computer algorithms. If the response rate following the first mailing was insufficient, a second mailing, excluding responders to the first, followed. The number of questionnaires sent out during the second mailing was based on the percentage response (per specialist group) to the first mailing in a particular country, if sufficient additional addresses were available. If not, the complete mailing was repeated. Due to meagre responses to the first mailing, a second one was carried out in all countries.

The first questionnaires of the PCP and specialist surveys were sent out between October 2002 and January 2003. The databases were closed in June 2003.

Data analysis

The database was created in Microsoft Access. All questionnaires were single-entered into this database and checked for inconsistencies. In addition, one out of 15 records was double-entered and was checked for data entry mistakes. After closing the database, variables were recoded where appropriate. Results were tabulated in a descriptive way. For each possible answer, the counts and proportions were given for the separate countries and the overall total. To test the differences between C and I/G, within each physician group, and between countries, the Chi-square test was used. Countries with non-overlapping confidence intervals were considered different from each other. For all analyses, a value of P < 0.01 was considered significant. All analyses were performed with STATA version 6.0.

Results

Response rate

Completed questionnaires were returned by 2041 C and 1881 I/G (29% of these were geriatricians). Response rates for C varied from 11% (160) in Spain to 35% (182) in the Netherlands (overall 25%) and for I/G between 11% (the Netherlands, 156 I/G) and 40% (Romania, 73 I/G) (overall 18%). Completed questionnaires were available from 2965 PCP. The average response rate overall was 13% and varied between countries, with the highest response from Romania (23% to the first mailing, 462 PCP) and the lowest from France and Germany (9% response rate each over two mailings, 292 and 331 PCPs, respectively).

Diagnosis of congestive heart failure

Specialists

Only 71% I/G indicated that they would routinely perform an echo and 43% an echo-Doppler, compared with 92 and 82% C, respectively (both P < 0.0001) (Table 1).

View this table:
Table 1

Diagnostic procedures in a patient with a clinical suspicion of heart failure of unknown aetiology by European specialists

CardiologistsInternists/Geriatricians
NlFrSpItRoUKSwPlGeAllNlFrSpItRoUKSwPlGeAll
ECG (%)
 Routine9910099100991009999999997939796999998999998
 Clinical indication10101011113522011011
 Not perform00000000000110000000
Chest X-ray (%)
 Routine87689690929050*9039*7994879792939764906185#
 Clinical indication1124485946*1052*18612357231*833*12
 Not perform04001021510111002021
Echo (%)
 Routine9488919284949194989260647774828159796571#
 Clinical indication2664145750529191411121132182319
 Not perform46342121232721000012
Echo Doppler (%)
 Routine8883858257*887678948227*474852643726*474843#
 Clinical indication891312338201951360*384139233456454343
 Not perform021051110156517147436
Exercise test (%)
 Routine42114111312181959*191897101410162049*17+
 Clinical indication517075647481657534*67647677616374587139*64
 Not perform312161911312439121312222110155512
Exercise+VO2 (%)
 Routine36171422741323002242#
 Clinical indication5846475926*45484149474447404925353418*4939
 Not perform30424019*64444248323944444825645151703046
Holter (%)
 Routine18158344103274918495254622140*15+
 Clinical indication7670845879878969487486618868738874735473
 Not perform4116313152156264215216317
Right heart cath (%)
 Routine72001311120000100000#
 Clinical indication7651745746845553616368406844364323*296045
 Not perform1341203445103838302924542439524363603043
CAG (%)
 Routine15149511812411111611101322#
 Clinical indication8283868669817994858382738676687057798475
 Not perform127726*071151018816222031*13916
BNP/proBNP (%)
 Routine2614302416141417181913102021811813913
 Clinical indication373335472218393246343931423811*1936264533
 Not perform25491812*44584242263739441814565439482636
  • Abbreviations: BNP, brain natriuretic peptide; CAG, coronary angiography; cath, catheterization; Fr, France; Ge, Germany; It, Italy; Nl, Netherlands; Pl, Poland; Ro, Romania; Sp, Spain; Sw, Sweden; UK, United Kingdom.

  • *P < 0.01 vs. other countries, +P < 0.01, P < 0.001, #P < 0.0001 cardiologists vs. internists/geriatricians.

Nearly all C and I/G performed a 12-lead ECG and chest X-ray routinely, but other investigations only on clinical indication. However, there were significant between-country differences (Table 1).The use of natriuretic peptides was low overall. More than one-third of C and I/G would not use natriuretic peptides for the diagnosis of HF.

Primary care physician

Seventy five per cent PCP reported that they often or always diagnosed HF by signs and symptoms alone (and 21% often or always by symptoms alone) (Table 2). Only 35% would often arrange for further investigations, whereas 22% thought that a response to diuretics was necessary to confirm the diagnosis. Only 9% PCP reported that they would reach a diagnosis of HF after referral to a specialist. Approximately 60% of respondents considered an ECG, chest X-ray, and echocardiogram necessary for diagnosis (Table 2). Again, the proportion varied by country. Echocardiography was considered necessary by 85% of Italian compared with 49% of Dutch PCPs.

View this table:
Table 2

Diagnostic procedures European PCPs use to detect heart failure

NLFrSpItRoUKSwPlGeTotal
Of those patients that YOU have diagnosed with heart failure, how did you come to that conclusion?
 Response rate (n)3092922983004603752883013312954
 Non-responders20112320011
On symptoms alone
 Never (%)15173216294230331526
 Occasionally (%)43394234264152333438
 Often (%)34341729141114143021
On symptoms plus signs
 Never (%)3201234112
 Occasionally (%)16221716202741161020
 Often (%)80738279746955838875
Only after further investigations
 Never (%)2693311123
 Occasionally (%)62434028323840372938
 Often (%)27313729265147314035
Only after referral to hospital specialist
 Never (%)5121713461918710
 Occasionally (%)89706953498371476766
 Often (%)3631021348159
When you investigate a patient with possible heart failure which tests do you believe are necessary and which tests so you believe are supportive to diagnose heart failure? (indicate all that apply)
 Response rate (n)3092902983004583762853013312948
 Non-responders22114250017
ECG
 Not applicable (%)1413244126167
 Supportive (%)5814402921644811*2935
 Necessary (%)28*7358667424*46886558
Chest X-ray
 Not applicable (%)22208335105
 Supportive (%)45222531195761113534
 Necessary (%)53567561773934876561
Echocardiography
 Not applicable (%)10322523144
 Supportive (%)43463713372922263232
 Necessary (%)47516185586975736464
Response to diuretics
 Not applicable (%)9301337182117151419
 Supportive (%)61476045516774646259
 Necessary (%)3023261831129212422
  • *P < 0.01 vs. other countries. Abbreviations as in Table 1.

Only 50% could obtain an echocardiogram directly (16%) or via specialists (34%) within 1 month compared with 94% and 91% for an ECG or a chest X-ray, respectively (Table 3). There were large differences between countries. Direct access to echocardiography was poor in nearly all countries.

View this table:
Table 3

PCPs’ access to diagnostic tests for heart failure

NLFrSpItRoUKSwPlGeTotal
ECG
 Access within 1 month
  Direct (%)98769966399390229975
  Through specialist (%)145643138812919
 Access at 1–3 months
  Direct (%)13010621513
  Through specialist (%)42541041114
 Not available0000210000
Chest X-ray
 Access within 1 month
  Direct (%)98779567279870253465
  Through specialist (%)1450429454936826
 Access at 1–3 months
  Direct (%)12053115915
  Through specialist (%)4244843124
 Not available0000100120
Echocardiography
 Access within 1 month
  Direct (%)154152641614111816
  Through specialist (%)375112544811257234
 Access at 1–3 months
  Direct (%)78992262611314
  Through specialist (%)4483535212937251426
 Not available1311404111836
  • Abbreviations as in Table 1.

Pharmacotherapy

Angiotensin-converting enzyme-inhibitors

Significantly fewer I/G than C indicated that they use an ACE-inhibitor in ≥90% of their patients (64 vs. 83% C, P < 0.0001, Table 4) and only 43% PCP would always (51% often) prescribe an ACE-inhibitor (Table 5); 13% I/G and 24% PCP would not prescribe an ACE-inhibitor in asymptomatic patients with LV dysfunction already on a diuretic (vs. 4% C, P < 0.0001). Also, more C than I/G and PCP would reach target doses of ACE-inhibitors (Figure 1).

Figure 1

Percentages of cardiologists (grey bars), internists/geriatricians (black bars) and PCP (striped bars) who would prescribe target dosages of ACE-inhibitors, recommended in the ESC guidelines on diagnosis and treatment of heart failure. ACE, Angiotensin converting enzyme; LVEF, left ventricular ejection fraction; NL, The Netherlands; Fr, France; Sp, Spain; It, Italy; Ro, Romania; UK, United Kingdom; Sw, Sweden; Pl, Poland; Ge, Germany. *P < 0.01 vs. cardiologists

View this table:
Table 4

Prescription of ACE-inhibitors and β-blockers by European specialists

CardiologistsInternists/Geriatricians
NLFrSpItRoUKSwPlGeAllNlFrSpItRoUKSwPlGeAll
Do you use an ACEi (%) in
 >90% of patients8785818368*857978908371596868706544*796264#
 50–90%1213171725152021101623312527213244193229
 30–50%113150110157658310166
 <30%00002001001410102101
Do you use a BB(%) in
 >90% of patients37232111232647*3056*29886516514211611#
 50–90%4738454143524248394421172519402133393828
 30–50%1327263821198175212913*3039292930253029
 10–30%21067843205272428265*30181010*20
 <10%12125003011539*1211101556612
ACEi are not prescribed (%)
 No symptoms + diuretics535410*1381419157710101992013#
 Creatinine >200 µmol/L3337564157404738294131484645665765473849#
 SBP < 100 mmHg2145551559192054313334535324*645344554045#
 Old age (>70 years)00107*002011111300121
 Serum sodium <130 mmol/L514151415922191314814717261627201517
 Cough303969594718*15*494539413352655122*29535545+
BB not prescribed (%)
 Mild HF + ACEi/diuretic9111414187111261119352329153129212426#
 Heart rate < 60 beats/min196912171391561233232424231817241822#
 Old age (>70 years)111111*1030238313*1043325#
 COPD4273727551533064465864677870517840*657468#
 SBP <100 mmHg20*41425240183045293538554850524151513947#
 Unstable HF5375755263744748636237577034666843434650#
 NYHA IV HF2537303032188*18152429313535413314*333531#
  • ACEi, ACE-inhibitor; BB, β-blocker; COPD, Chronic obstructive pulmonary disease; HF, heart failure; NYHA, New York Heart Association classification; SBP, systolic blood pressure. Other abbreviations as in Table 1.

  • *P < 0.01 vs. other countries, +P < 0.01, P < 0.001, #P < 0.0001 cardiologists vs. internists/geriatricians.

View this table:
Table 5

PCPs' estimation on how often they prescribe the following drugs

NLFrSpItRoUKSwPlGeTotal
Response rate (n)3092922983004603752883013312954
Non-responders (n)20112320011
Diuretic
 Never (%)0000010000
 Occasionally (%)2226234343
 Often (%)61395428406159625651
 Always (%)37594466583637354046
Digoxin
 Never (%)11572179045
 Occasionally (%)74416333128281526053
 Often (%)15492645471110433332
 Always (%)0542141004410
β-Blocker
 Never (%)2215181282231211
 Occasionally (%)56505149565850343048
 Often (%)20303033301943565835
 Always (%)25267149115
ACE-inhibitor
 Never (%)0110001000
 Occasionally (%)79631036446
 Often (%)62525042486159345051
 Always (%)31374355423634624543
Calcium antagonist
 Never (%)46283832195349192934
 Occasionally (%)48545149664143665853
 Often (%)61810171367131311
 Always (%)0112200211
Angiotensin_II antagonist
 Never (%)142097667335519
 Occasionally (%)63506946297264596257
 Often (%)212821404213052922
 Always (%)2217103142
Nitrates
 Never (%)791776201521911
 Occasionally (%)57465745366352395650
 Often (%)33392537421730522133
 Always (%)251111603746
Aldosterone receptor antagonist
 Never (%)94611454145
 Occasionally (%)55345440507161226951
 Often (%)32563636392332672638
 Always (%)364128121125
  • P < 0.01 vs. other countries. Abbreviations as in Table 1.

Approximately half of all C and I/G considered renal impairment, hypotension and hyperkalaemia a high risk of ACE-inhibitor use and approximately 25% C and 30% I/G would stop or adapt therapy in these instances. PCPs were less concerned, except for cough (55%) (Figure 2). Thirty-eight per cent C and 35% I/G would change or stop (and 47% PCP stop) treatment because of cough. Of interest, quite a few physicians in each group believed that ACE-inhibitors carried some risk of bronchospasm, cold extremities, impotence, and even worsening HF.

Figure 2

European primary care physicians perception of the risks of ACE-inhibitor treatment (A) and β-blocking therapy (B) in heart failure (striped bar: high risk; closed bar: low risk; open bar: no risk)

β-Blockers

Only 5% PCP stated that they would always and 35% often prescribe a β-blocker (although there were considerable between-country differences, Table 5) and 11% would never prescribe it. Moreover, target doses of β-blockade would only be reached in seven (metoprolol) to 29% (carvedilol) of cases. Also, considerably fewer I/G (39%) than C (73%) would prescribe a β-blocker in ≥50% of their patients (P < 0.0001) (Table 4). More I/G (26%) than C (11%, P < 0.0001) and 35% PCP indicated that they would not treat patients with mild HF already on an ACE-inhibitor and a diuretic with a β-blocker. Conversely, only 45% PCP would not prescribe this treatment to a patient with unstable HF. Significantly less I/G than C would not prescribe a β-blocker in case of old age, NYHA class IV, a systolic blood pressure <100 mmHg, heart rate <60 beats/min and chronic obstructive pulmonary disease (COPD) (Table 4), whereas >80% of PCP would not prescribe in case of bradycardia and COPD (Table 6).

View this table:
Table 6

Reasons for European PCPs not to prescribe an ACE-inhibitor or β-blocker

NLFrSpItRoUKSwPlGeTotal
When do you not prescribe an ACE-inhibitor? (tick all that apply)
 Response rate (n)3032852972984543772783003282920
 Non-responders (n)872381121325
 Renal artery stenosis (%)7255*8756*589486917374
 Cough (%)4655587223*27*36586247
 BP<100 mmHg (%)32434429494550594344
 Creatinine>150 µmol/L (%)40523525285657464142
 Symptom free on diuretic (%)41112518152425164024
 Serum Na < 130 mmol/L (%)1225161093332171619
 Old age (%)0443722343
When do you not prescribe a β-blocker? (tick all that apply)
 Response rate (n)2742662822994583382742993222812
 Non-responders (n)37261724401629153
 Bradycardia (%)90869190838177928586
 COPD/asthma (%)77919584739378878584
 Unstable heart failure (%)41536323336149483945
 Mild symptoms on ACE-inhibitors + diuretics (%)4456423317474193535
 Systolic BP < 100 mmHg (%)22332916332126402828
 Old age (%)7102020195110611
 Cough (%)4334875696
 Tachycardia (%)1110121301
  • P < 0.01 vs. other countries. ACE, angiotensin converting enzyme; BP, blood pressure; COPD, chronic obstructive pulmonary disease. Other abbreviations as in Table 1.

Other pharmacotherapy

The majority of C and I/G stated that they would prescribe an angiotensin receptor blocker (ARB) only in case of intolerance to ACE inhibition. Less than 10% reported adding an ARB to an ACE-inhibitor with persisting symptoms (PCP 7%). Significantly more Dutch C (37%) and I/G (46%) would use an ARB as a routine alternative to ACE inhibition (compared with C and I/G in other countries).

Most C and I/G indicated that they would prescribe digoxin in mild (NYHA I–II) HF only in selected cases (e.g. those with atrial fibrillation). Conversely, approximately half of C and I/G would prescribe digoxin regularly (i.e. in >30%) in patients with NYHA III and IV HF. Slow-release dihydropyridine calcium antagonists were prescribed by significantly more I/G (30%) than C (15%) in >10% of their patients. Also, significantly more I/G than C would use verapamil or diltiazem in >10% of their patients (31 vs. 5%, respectively).

Prescription rates for digoxin, aldosterone antagonists and nitrates by PCP mimicked those for β-blockers, although there were considerable between-country differences (Table 5).

Order of treatment

Primary care physician

Diuretics were the preferred single agent for initiation of treatment (Table 7). ACE-inhibitors (either alone or in combination with a diuretic) would be used to initiate treatment by only just over 50% of respondents. An average 34% of respondents would add a β-blocker in a patient who continued to have symptoms or worsened despite optimal treatment with a diuretic and an ACE-inhibitor. More would prescribe spironolactone (44%) or digoxin (38%), and approximately 50% would refer the patient for specialist care.

View this table:
Table 7

Treatment strategies for heart failure by European PCPs

NLFrSpItRoUKSwPlGeTotal
With what medication do you start the treatment of heart failure in most patients? (tick one answer)
 Response (n)2852752852674323682702643212767
 Non-responders (n)261714343010203710198
 ACE-I (%)17142116252227362723
 Diuretic (%)57544211*21*634216*3939
 ACE-I+ diuretic (%)22283551281425412229
 β-Blocker(%)0001001121
 ACE-I+β-Blocker+diuretic (%)3428704985
 Digoxin (%)030624*00425
 Angiotensin-II antagonist (%)1000000000
Which of the following medications do you prescribe when you observe a worsening of the symptoms, when the heart failure patient is already using an optimal dose of diuretic and ACE-inhibitor? (tick all that apply)
 Response (n)3072912982994593762803003302940
 Non-responders (n)411232101125
 Add spironolacton (%)5243444116*5950604244
 Add digoxin (%)31293148492223604438
 Add β-Blocker (%)30162828122465*50*64*34
 Add calcium antagonist (%)8489240585
 Add angiotensin-II antagonist (%)11241018106127
 Send to specialist (%)56764443467643344752
  • *P < 0.01 vs. other countries. ACE-I, angiotensin converting enzyme inhibitor. Other abbreviations as in Table 1.

Specialists

In mild–moderate, stable HF without signs of fluid retention, 58% C and 64% I/G reported they would start treatment with an ACE-inhibitor, whereas 25% C would start with an ACE-inhibitor and a β-blocker, up-titrated one after the other (vs. 13% I/G, P < 0.001). Few would start with only β-blockade.

If signs of fluid retention were present, most C and I/G (48 and 50%, respectively) would start with a diuretic only, and 40% C and 37% I/G with a diuretic and an ACE-inhibitor at the same time.

When asked whether, in mild HF (NYHA class I–II), diuretics alone are sufficient, 18% I/G agreed (31% in Germany) vs. 7% C (P < 0.001).

Worsening HF symptoms in a patient in sinus rhythm and already receiving optimal doses of ACE inhibition, β-blockade and diuretics would prompt more C than I/G to add spironolactone, whereas more I/G would add digoxin (Figure 3).

Figure 3

What cardiologists (grey bars) and internists/geriatricians (black bars) would do in a patient with worsening HF symptoms in sinus rhythm and on optimal ACE-inhibitors, β-blockade (BB) and diuretics. ARB, angiotensin receptor blocker; CRT, cardiac resynchronization therapy; iv, intravenous. Other abbreviations as in Figure 1. *P < 0.01 between specialists

Referral to a specialist

Only 55% PCP would send patients with mild-to-moderate HF, aged 65–80 years, to a specialist and only 32% would refer patients over 80 years (10% in the Netherlands).

How medical specialists obtain information on heart failure

Although guidelines scored the highest among C, they were only chosen by 32%, followed by expert opinion (30%), and review articles (18%). Expert opinion scored the highest among I/G (31%), whereas only 27 and 21% selected guidelines and review articles, respectively. Guidelines scored the highest in the Netherlands, but very low in Romania where expert opinion was particularly highly regarded.

Discussion

This survey into the awareness and perception of different aspects of HF among C, I/G and PCP in nine European countries, selected to represent Europe geographically, indicates that, despite widespread availability of evidence-based HF guidelines, differences between physicians and countries exist in HF management. These differences were particularly apparent in the necessity to determine cardiac function (in particular the use of echocardiography as a routine diagnostic tool), prescription of ACE inhibition and β-blockade, use of low doses of these agents, reliance on diuretics as single treatment in HF, use of inappropriate drugs, and timing of medication.

The SHAPE survey is the only prospective multi-country European study to provide a comparison between awareness and perception of HF among C and I, and a contemporary analysis of those of PCPs in the same countries.

There are several prior between-specialist comparisons of HF management from single countries in Europe, which have reported differences in practice. A French study, conducted in 1997, showed no difference in the use of echocardiography and ACE-inhibitors by I compared with C but both were used less by geriatricians.17 In contrast, an Italian study, conducted in 1998, showed higher rates of the use of echocardiography, ACE-inhibitors, and β-blockers (and adherence to guidelines) by C compared with I.18 The only prior multinational data come from the Euro HF I study that provided information on ACE-inhibitor and β-blocker use at discharge from cardiology and general internal medicine wards in 24 European countries in 2000–1. These drugs were prescribed significantly less often in patients discharged from internal medicine wards.7 Because, however, the patients discharged from these two types of wards differed (those from internal medicine wards were older, had more co-morbidity, etc.), it was difficult to know whether the prescribing differences reflected physician knowledge and practice or patient characteristics.19 Our data suggest that the different treatment of patients discharged from internal medicine and cardiology wards, at least in part, reflects differences between specialists in their perception of the diagnosis and treatment of patients with HF.

PCPs’ perception of recommended diagnostic approaches and treatment options in HF are of concern. Most think that diagnosis can be made on the basis of symptoms and signs alone. Although 64% of PCPs consider an echocardiogram necessary and 32% supportive to establish the diagnosis of heart failure (a figure not too different from the 92% of specialists who perform echocardiography routinely in this case), only one-third would often arrange for it to diagnose HF. This might be at least partly explained by the availability of echocardiography; in most countries, echocardiography was not available to more than half of the PCPs within 1 month, or not available at all (e.g. Romania), and this would obviously impact on their usage by the PCP. It is very disappointing that lack of access may still be a problem, as this had been highlighted in earlier surveys such as the Euro-HF study8 (which, like SHAPE, was a questionnaire-based survey) and in the IMPROVEMENT-HF study9 (interview-based and an actual practice survey) which were conducted almost a decade ago. Of interest, in the IMPROVEMENT study, 48% PCPs reported to routinely use an echo for the diagnosis of HF20 as compared with our later survey, in which only 35% indicated to often arrange for investigations, including echo. Whether this failure to improve over time is the fault of healthcare providers (to recognize this as a public health problem and provide funding and resources), secondary care physicians (to be interested in the problem of HF in the community and provide service to their primary care colleagues) or PCPs (to recognize the need for echocardiography and demand its availability), or some combination of these, is unknown. Clearly, this needs to be identified and resolved before the most valuable diagnostic investigation is made universally available to European HF patients.

Our results also show that HF treatment in primary care has changed little due to the previous surveys.8,9 PCPs still do not follow the European and other guidelines, which consistently recommend ACE-inhibitors as first-line therapy for all patients with reduced left ventricular systolic function.35 Indeed, we found that many respondents stated that they would start their treatment with only a diuretic and less than half of them perceived the need to use ACE-inhibitors in all HF.

That β-blockers further reduce morbidity and mortality when added to an ACE-inhibitor became evident in 199911,12 and was clearly stated in guidelines available before our survey.3,4 Despite this, only 5% PCPs in SHAPE state that they would always (and 35% often) prescribe a β-blocker. Indeed, 11% would never prescribe a β-blocker and 35% would not prescribe it to a patient with mild symptoms on treatment with an ACE-inhibitor and diuretic. Moreover, a large majority of physicians reported that they would not reach the recommended target dosages of ACE-inhibitors or β-blockers.4 One contributing reason may be that there is a general concern and over-estimation of the risk of side-effects with these drugs,8 increasing the likelihood of not starting them or inappropriate dosing. These concerns were expressed by PCPs and I/G (more than by C). Changes in blood pressure and serum creatinine are usually small with ACE inhibition in normotensive patients without severe HF, and symptomatic hypotension is uncommon. Also, whereas β-blockade may lead to worsening HF, bradycardia, and hypotension in a few patients, these effects are usually not dangerous, and are rapidly reversible, provided that patients are stable and up-titration is slow, starting from a low dose. In MERIT-HF21 study, blood pressure in patients receiving β-blockade fell less than in the placebo group. Furthermore, there is a misconception that bronchospasm often occurs with β-blockade in HF. Combined non-selective β- and α-adrenergic blockade is well tolerated in HF patients with COPD.22

Only ∼50% PCPs said that they would refer a patient in the typical age range of HF (65–80 years) to a specialist, and few would do this in the elderly. In this context, the fact that many PCPs believe that they can, or are obliged to, detect HF based on symptoms and signs alone, is of concern. A correct diagnosis of HF requires objective evaluation of cardiac function. This is particularly important in the elderly, in whom the preponderance of women and high prevalence of co-morbidities make a correct diagnosis based on symptoms and signs alone even more hazardous.

Our finding that I/G report practices that frequently deviate from those recommended in guidelines is also of concern, as many patients admitted to hospital with HF are cared for by these specialists.

One obvious reason for why I/G report poor adherence to guideline-recommended practice is that they have not read the relevant guidelines. And that is exactly what we found when we asked physicians in our survey to report what influenced their practice. That I/G do not read the guidelines has also been reported in a single country survey.23 Moreover, the same authors reported from a similar PCP survey that while most PCPs were aware of the existence of a national guideline (SIGN), many had not read it.24 This is a worrying finding that points to a failure of international and national societies to reach an important target audience. Guidelines on the management of HF have been written mainly by C and published by cardiac societies and in cardiology journals. Consequently, non-cardiologists may not have access to the guidelines or may not feel that they are relevant to them. Ideally, guidelines should be put together by an optimal mix of C, I/G, PCP, and HF nurses, to assure their proper representation, and should be disseminated by appropriate medical and nursing organizations, and not just cardiac societies.

Although C may do better than I/G, they are not perfect in their adherence to guideline-recommended practice (not surprising, as only 32% C stated that guidelines had most influence on their decisions in HF management). For example, only 58% C would add spironolactone in a patient in sinus rhythm with worsening symptoms of HF despite optimal treatment with an ACE-inhibitor, β-blocker, and diuretic. In Romania, Italy, and Spain, this proportion was even lower. As SHAPE was carried out before August 2003, the results of the CHARM25,26 trial did not affect the SHAPE survey—in fact angiotensin receptor blockers only scored 1% in this question. Approximately 20% of C in Romania, Poland, and Italy stated that they would use digoxin instead, whereas similar percentages in Spain and France would reduce the dose of β-blocker. These findings highlight the need for continuing reinforcement of evidence-based practice through any possible means, e.g. registries aiming at improving outpatient HF care, such as IMPROVE HF,27 targeted at C.

Limitations

In both surveys, there was a relatively low response rate, which was expected based on experiences in earlier similar type of surveys. Nevertheless, the target numbers were reached. Whether those who responded were representative of the overall physician's group receiving a questionnaire would require a sensitivity analysis, which was not possible in this survey. Although a small response rate may introduce a bias, it is likely that those physicians who responded were the ones more interested in and more aware of HF. Accordingly, the knowledge of guideline-recommended approaches to the diagnosis and treatment of HF may be even less in the majority of physicians who did not respond to the survey.

An interview-based survey in contrast to an actual-practice study may not reflect what really happens with the patients in physicians' practices, but rather their perception of what they do or should do in managing them. It is likely that collecting data directly from patients could have further reduced the rate of adherence to guidelines.

A further limitation is that there are no data on the typical age of patients in different specialist practices nor in those of PCPs. Patients are likely to be older in geriatric and possibly internist and PCP practices than those seen by C. Age and greater co-morbidity in the elderly may influence perception and practice of different healthcare providers and their adherence to guidelines. Indeed, in a previous survey PCPs did indicate that they felt comfortable treating older patients with significant co-morbidity on the basis of a clinical diagnosis of HF.24 This may explain in part the different diagnostic and therapeutic approaches of these physicians.

Conclusion

In conclusion, despite evidence-based guidelines, between-physician differences in the management of HF persist. In particular, the perceptions of the European PCP and I/G in aspects of HF, including the use of diagnostic techniques and pivotal therapies such as ACE-inhibitors and β-blockade, are not optimal. Consequently, there is significantly less uptake of recommended management strategies in their practices. As these non-cardiology physicians care for many HF patients educational programmes to increase their awareness and perception of HF are clearly needed. In addition, research on methods to improve implementation of evidence-based medicine and the European guidelines for management of HF in primary and non-cardiologist secondary care should be encouraged. Education apart, integration in multidisciplinary groups, including specialized nurses and C, may further increase the pivotal role of both the PCP and I/G in the management of HF.

Study of Heart Failure Awareness and Perception in Europe steering committee

W.J. Remme (Chairman), A. Boccanelli, C. Cline, A. Cohen-Solal, R. Dietz, F.D.R. Hobbs, J. Lopez Sendon, C. Macarie, J. McMurray, B. Rauch, W. Ruzyllo, F. Zannad.

Study of Heart Failure Awareness and Perception in Europe study group

The following members of the SHAPE study group critically reviewed the questionnaires:

France: J.M. Boivin, S. Briancon, A. Cohen-Solal, F. Zannad; Germany: W. Assen, Ch. Zugck, R. Dietz, B. Rauch; Italy: A. Boccanelli, G.F. Gensini, P. di Giulio, B. Guillaro, C. Opasisch, M. Scherillo; The Netherlands: D. Grobbee, A. Hoes, T. Jaarsma, W.J. Remme, D.J. van Veldhuisen; Poland: J. Grzybowski, M. Jedras, W. Ruzyllo; Romania: I. Bruckner, R. Cristodorescu, D.E. Falnita, C. Macarie, E. Petromaneantu; Spain: P. Conthe Gutierrez, J.M. Lobos Bejarano, J. Lopez Sendon; Sweden: N. Göran Ahlin, C. Cline, A. Iwarsson, G. Johansson; UK: F.D.R. Hobbs, M. Lye, J. McMurray.

Conflict of interest: none declared.

Funding

The study was funded by an unrestricted grant from The Sticares Cardiovascular Research Foundation; Pfizer Inc.; F. Hoffmann-La Roche; Servier International; Medtronic Foundation; Guidant Europe Nv/Sa; GlaxoSmithKline; Abbott International; Chiesi Farmaceutici S.p.A.; Merck KGaA.

References

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