Heart failure is a condition in which the heart is unable to pump blood at the rate needed to fulfil the body’s metabolic needs, or only at the cost of high filling pressures. It results from functional or structural heart disorders decreasing the heart’s ability to fill or pump, and thus may have several causes, e.g. myocardial infarction, valvular disease, hypertension and atrial fibrillation. Heart failure (HF) is a clinical syndrome, not a single diagnosis. Identification of the underlying cardiac dysfunction is mandatory in the diagnosis of HF, since this will determine subsequent treatment.
Cardinal symptoms of HF are breathlessness, ankle swelling and fatigue. Symptoms increase during exacerbations. Signs at physical examination may be elevated jugular venous pressure, pulmonary crackles and peripheral oedema. Heart failure may become symptomatic at rest and / or during exercise.
Additional examination is indicated if heart failure is suspected, based on history and physical examination. A chest X-ray may help to differentiate from pulmonological causes for dyspnoea, such as showing cardiomegaly or pleural effusion. A (highly) elevated value of natriuretic peptide (BNP or NT-proBNP) makes HF (very) likely. An electrocardiogram (ECG) is advised when HF is suspected. A normal ECG makes HF unlikely, but an abnormal ECG does not yet demonstrate HF. Atrial fibrillation or a paced rhythm on the ECG increase the likelihood of the presence of HF. When HF is suspected and elevated (NT-pro) BNP and / or ECG abnormalities are present, echocardiography is indicated. The diagnosis of heart failure is normally made by the cardiologist, although in consultation with frail or elderly patients, referral to the cardiologist is sometimes omitted.
Cardiologists classify HF in three subgroups according to the left ventricle ejection fraction, which is generally assessed by echocardiography: heart failure with preserved ejection fraction (HFpEF), with mildly reduced ejection fraction (HFmrEF) and with reduced ejection fraction (HFrEF).
Treatment with medication is generally started by the cardiologist and often reduces the symptoms of HF. It can also prevent exacerbations and reduce mortality from heart failure. Daily medication is prescribed and dosed stepwise and includes renin-angiotensin system blockers (e.g. ACE-inhibitors) and diuretics when signs of fluid retention are present. Betablockers may be added in stable patients. Medication is normally needed life-long. Patients may be advised to take extra diuretics when fluid retention increases (ankle edema, weight gain). In the continuation of the treatment, GPs often contribute. Acute decompensations require prompt management.
Heart failure is coded with the ICPC-2 code K77.
In addition, the underlying disease(s) will be coded, e.g. myocardial infarction (K75), atrial fibrillation (K78), heart valve disease (K83) and hypertension (K86).
Symptom diagnoses may be coded if there is no diagnosis of heart failure, for example: shortness of breath / dyspnoea (R02), swollen ankles / oedema (K07) or weakness / tiredness general (A04).
Heart failure is a disease of older aged patients. The incidence is 1.4 per 1000 patient years across all age groups, meaning three new diagnoses of HF per 2000 patients per year. In the age group 65-74, this is 3.6, and in the age group 75+, it is 19.4 per 1000patient years. Link/Figure 1
The difference in incidence between men (5.1) and women (2.1 per 1000 patient years) in the age group 64-75 is a well described phenomenon and demonstrates the differences in the underlying causes of HF and differences in the timing of first onset of cardiovascular disease. In women, cardiovascular decline starts in the years after menopause when the ‘hormonal umbrella of cardiovascular protection’ disappears.
The overall prevalence of HF is 7.3 per 1000 patient years and is slightly higher in women then in men. Link/Figure 2 This means that, among 1000 patients in a year, seven individual patients search for help from their GP for HF.
Among the oldest patients (age 75+), this is 101.3 per 1000 patient years, meaning that 10% of these patients are affected by HF and contact their GP for it throughout the year. In this age group, HF ranks 13th among the most prevalent conditions. Link/Table 3 The higher prevalence compared to incidence reflects the chronicity of HF, requiring ongoing attention after the diagnosis.
Shortness of breath (R02) is by far the most common reason for encounter (RFE) before the first diagnosis of heart failure, followed by swollen ankles (K07) and suspicion of heart failure (K77). HF also commonly starts with the RFE ‘administrative contact’ (*62). This means that the diagnosis is likely reported for the first time in a (specialist) report to the GP and then added to the electronic health record. Episodes of HF also commonly start with a request for examination (*31), medication prescription (*50) or a test result (*60). The latter means that a new diagnosis of HF is made after tests performed within the course of another episode of care. This shows that HF is not diagnosed as an isolated condition but follows on from other heart disorders. Other common symptoms presented at the start of episodes of HF are tiredness (A04) and cough (R05). Link/Table 4
Age and sex have no (relevant) impact on which signs and symptoms are presented.
GPs appear to manage a substantial amount of the workload from heart failure patients themselves. Medication for HF is prescribed by GPs in 83% of all episodes per year. Laboratory tests are recorded by the GP in 21% of episodes per year. Diagnostic imaging (chest X-rays) and electrocardiograms occur in 2% of episodes per year. Specialist referrals and consultations occur in 11% and 6% of episodes per year, respectively. Link/Table 5 It seems that care for patients with HF is provided partly in primary and partly in secondary care. Referrals to secondary care mainly involve cardiology, but also internal medicine and pulmonology. Link/Table 6 Primary care referrals for HF are rare and involve home care, physical therapy and other care providers. Link/Table 7
The most prescribed medication type in episodes of HF is lisdiuretics (furosemide, bumetadine), in 59% of all episodes of heart failure, followed by aldosterone agonists (spironolactone, eplerenone, 19%), beta blockers (17%) and ACE inhibitors (15%). Link/Table 8
Note that all intervention reports show only interventions (including referrals and prescriptions) that are linked specifically to the episode heart failure (K77). Underreporting is likely, since interventions may also be registered under the ICPC code of the underlying cause of heart failure. This is specifically the case for prescriptions, since all prescribed medication must be linked to one episode in FaMe-Net, including in patients with multiple reasons (episodes) to prescribe. For example, medication that may also be prescribed for other episodes (e.g. statins or antihypertensives for ischaemic heart disease, K76) can and will often be reported under the alternative ICPC code.
Dutch guideline: https://richtlijnen.nhg.org/standaarden/hartfalen#volledige-tekst (2021)
Colucci WS. Heart failure: Clinical manifestations and diagnosis in adults. In: UpToDate, Gottlieb SS, Dardas TF (Eds), UpToDate, Waltham, MA, 2022
McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, Burri H, Butler J, Čelutkienė J, Chioncel O et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: Developed by the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). With the special contribution of the Heart Failure Association (HFA) of the ESC. European Heart Journal, Volume 42, Issue 36, 21 September 2021, Pages 3599-3726. https://doi.org/10.1093/eurheartj/ehab368