Hobbs F D
Department of Primary Care and General Practice, University of Birmingham Medical School.
Br J Gen Pract. 2000 Sep;50(458):735-42.
Heart failure is an increasingly common and costly chronic disorder, with a rising prevalence of at least 2% in populations over the age of 45 years, mortality rates that are as poor as common solid cancers, and very high health care utilisation costs. Despite increased evidence supporting a range of effective interventions, predominantly therapeutic, there remain significant degrees of physician underperformance in terms of heart failure diagnosis and management. Until the early 1990s, the management of heart failure was largely confined to the symptomatic relief of patients with well established heart failure in fluid overload. The introduction of angiotensin-converting enzyme (ACE) inhibitors provided the first treatments that beneficially altered the prognosis of patients with the most common expression of heart failure, namely established systolic dysfunction, whether symptomatic or asymptomatic. Evidence has now extended these benefits to delaying progression of heart failure and reducing hospitalisation. Much of our understanding of the pathophysiology of heart failure stems from these studies. More recent data has clarified the limited role of digoxin, the important benefits of beta-blockade and aldosterone blockers as adjuvants to ACE inhibition, and the emerging evidence on angiotensin II antagonists. There are, in contrast to these positive findings, reliable data from Europe and North America revealing significant underperformance of primary care and hospital physicians in heart failure diagnosis and management, with evidence of underuse and underdosing of evidence-based therapies. Limited qualitative data suggest the reasons for this underperformance are complex and relate to lack of access to objective testing of ventricular function and exaggerated concerns over treatment risks and side-effects. Heart failure represents a complex cluster of aetiologies and risks that are not easy to correctly identify, even in specialist settings. Since there is now powerful evidence on how heart failure can be modified and improved, explicit guidance is needed for which suspected patients should be referred, for confirmation of diagnosis and advice on appropriate treatment regimes, and for which patients can be handled mainly within primary care but with enhanced access to objective non-invasive tests to improve diagnostic reliability and to stratify patients to evidence-based therapies. Current evidence suggests that in North America and Europe today primary care physicians do underperform in their management of patients with heart failure, often owing to factors outside of their immediate control.
心力衰竭是一种日益常见且代价高昂的慢性疾病，在45岁以上人群中的患病率至少以每年2%的速度上升，死亡率与常见实体癌相当，医疗保健利用成本极高。尽管越来越多的证据支持一系列有效的干预措施，主要是治疗性措施，但在心力衰竭的诊断和管理方面，医生的表现仍存在显著不足。直到20世纪90年代初，心力衰竭的管理主要局限于对已确诊的心力衰竭且伴有液体超负荷的患者进行症状缓解治疗。血管紧张素转换酶（ACE）抑制剂的引入提供了首批有益改变最常见心力衰竭类型（即已确诊的收缩功能障碍，无论有无症状）患者预后的治疗方法。现在有证据表明，这些益处还包括延缓心力衰竭进展和减少住院。我们对心力衰竭病理生理学的许多理解都源于这些研究。最近的数据阐明了地高辛的作用有限、β受体阻滞剂和醛固酮拮抗剂作为ACE抑制辅助药物的重要益处，以及关于血管紧张素II拮抗剂的新证据。与这些积极发现形成对比的是，来自欧洲和北美的可靠数据显示，初级保健医生和医院医生在心力衰竭的诊断和管理方面表现显著不佳，有证据表明循证疗法未得到充分使用和剂量不足。有限的定性数据表明，这种表现不佳的原因很复杂，与无法获得心室功能的客观检测以及对治疗风险和副作用的过度担忧有关。心力衰竭代表了一系列复杂的病因和风险，即使在专科环境中也不容易正确识别。由于现在有强有力的证据表明心力衰竭可以如何得到改善，因此需要明确的指导，以确定哪些疑似患者应转诊，以确认诊断并就适当的治疗方案提供建议，以及哪些患者可以主要在初级保健机构处理，但需增加获得客观非侵入性检测的机会，以提高诊断可靠性并将患者分层以接受循证疗法。目前的证据表明，如今在北美和欧洲，初级保健医生在心力衰竭患者的管理方面确实表现不佳，这通常是由于他们无法直接控制的因素所致。
