Only a quarter of patients with symptoms suggestive of heart failure are investigated and referred by GPs in accordance with NICE guidelines, a UK study has shown. Nearly 80% of heart failure patients were diagnosed in hospital.

The investigators, from Imperial College, London, extracted data on patients diagnosed with heart failure between 1 January 2010 and 31 March 2013, using the Clinical Practice Research Datalink. This database contains electronic records from 7% of general practices in England. Primary care consultations are linked to hospital admissions data and national death registrations for patients registered with participating practices.

The investigation and referral pathways followed by patients from first presentation with symptoms suggestive of heart failure through to diagnosis were traced.

Overall, 36,748 patients had a diagnosis of heart failure recorded that met the inclusion criteria. The vast majority, 29,113 (79.2%) had the diagnosis of heart failure first recorded in hospital. Of these, more than a third (37%) had consulted a GP in the previous year with recorded heart failure symptoms.

In the five years prior to diagnosis, 15,057 patients (41.0%) had a GP consultation with one of three key heart failure symptoms recorded (breathlessness, fatigue and ankle swelling). The most common symptom was breathlessness, recorded in 8 out of 10 cases. A further 17,724 patients (48.2%) attended for another reason and had no symptoms of heart failure recorded. In addition, 3,967 patients (10.8%) did not see their GP.

Only 24% of those with recorded heart failure symptoms followed the NICE pathway for investigation and referral (echocardiogram and/or serum natriuretic peptide test and specialist referral), while 44% had no echocardiogram, natriuretic peptide test or referral.

The early identification of patients with heart failure is important to initiate appropriate and prognostically important interventions. However, identifying such patients in primary care is challenging.

This study found that only a quarter of patients with symptoms suggestive of heart failure follow the pathway recommended by NICE guidelines.

As such the study authors conclude that there are likely to be missed opportunities for the earlier diagnosis of heart failure in primary care.

However, this was an observational study and dependent on accurate READ code entry for the recording of symptoms. The authors also acknowledge the lack of specificity of these symptoms in the diagnosis of heart failure.

The authors conclude that patients follow various pathways to the diagnosis of heart failure. ‘Most continue to be diagnosed in hospital despite many presenting earlier in primary care with suggestive symptoms.

‘Further research is needed to understand how GPs react to patients presenting with these symptoms and how they use current guidelines: there appears to be considerable opportunity to improve the early management of these patients in primary care,’ they state.

Dr Peter Savill

Bottle A, Kim D, Aylin P et al. Routes to diagnosis of heart failure: observational study using linked data in England. Heart 2018;104:600-05