Heart failure patients admitted to general wards twice as likely to die

The national heart failure audit for England and Wales 2008-2009

Heart failure patients admitted to general wards are twice as likely to die as those admitted to cardiology wards, shows a national audit of the treatment of the condition, published online in the journal Heart.

Women fared worse than men when it comes to appropriate investigations and treatment, the findings suggest, although death rates were similar.

In 2006/7, heart failure accounted for more than a quarter of a million hospital deaths and discharges in England and Wales, equating to around 2.5 million bed days a year and at an annual cost to the NHS of -563 million.

The authors draw their conclusions from a survey of the first 10 patients admitted each month with a primary diagnosis of heart failure to 86 hospitals across England and Wales between April 2008 and March 2009.

During this period, just over 6,000 patients, with an average age of 78, were admitted with the condition. Almost half of these (43%) were women.

At admission, less than a third (30%) were reported to be breathless at rest and under half (43%) as having swollen feet/ankles. These are both diagnostic features of heart failure.

Appropriate investigations were not always carried out, the survey shows, with those admitted to general medical wards less likely to receive these than those admitted to cardiology wards.

Most patients (75%) were given a heart trace monitor test (echocardiogram). But only two thirds of those (65%) admitted to general medical wards were given this test.

This showed that the left ventricular ejection fraction (LVEF), an indicator of the pump action of one of the two lower chambers of the heart, was 40% or less in most of those admitted.

But LVEF was not recorded in one in four patients. And those with an LVEF of under 40% or in whom LVEF was not recorded were more likely to be women, older, and managed on general medical wards.

Levels of natriuretic peptides, which are a much effective test for heart failure, and a much better barometer of likely outcome than LVEF, say the authors, were only measured in 1% of patients, despite National Institute of Health and Clinical Excellence recommendations.

Half the patients were admitted to cardiology wards. Compared with those managed on general wards, they tended to be younger and were more likely to be men. Those admitted to general medical wards were twice as likely to die as those admitted to cardiology wards, even after taking account of other risk factors.

While most patients, in whom discharge drug treatment was recorded, were given the appropriate medicines, only half were prescribed beta blockers. Men and younger patients were more likely to be given these drugs.

"Currently, hospital provision of care is suboptimal and the outcome of patents poor. The same rules that apply to suspected cancer should pertain to a disease with such a malign prognosis as heart failure," conclude the authors.

This means ready availability of natriuretic peptide testing, prompt referral to a specialist and appropriately trained staff to manage the condition during and after hospital admission, they say.

Source: BMJ-British Medical Journal