Remme Willem J, McMurray John J V, Hobbs F D Richard, Cohen-Solal Alain, Lopez-Sendon José, Boccanelli Alessandro, Zannad Faiez, Rauch Bernhard, Keukelaar Karen, Macarie Cezar, Ruzyllo Witold, Cline Charles
Sticares Cardiovascular Research Foundation, PO Box 882, 3160 AB Rhoon, The Netherlands.
Eur Heart J. 2008 Jul;29(14):1739-52. doi: 10.1093/eurheartj/ehn196. Epub 2008 May 27.
To assess awareness of heart failure (HF) management recommendations in Europe among cardiologists (C), internists and geriatricians (I/G), and primary care physicians (PCPs).
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 beta-blocker in >50% of their patients (vs. 73% C, P < 0.0001). Also, only 5% PCP would always, and 35% often, prescribe a beta-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 beta-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, beta-blockade and diuretics, significantly more C would add spironolactone, but I/G would more often add digoxin.
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.
评估欧洲心脏病专家（C）、内科医生和老年病医生（I/G）以及初级保健医生（PCP）对心力衰竭（HF）管理建议的知晓情况。
欧洲HF知晓与认知研究组（SHAPE）对法国、德国、意大利、荷兰、波兰、罗马尼亚、西班牙、瑞典和英国随机抽取的心脏病专家（2041名）、内科医生和老年病医生（1881名）以及初级保健医生（2965名）进行了调查。每位医生完成了一份关于HF（左心室射血分数<40%）诊断和治疗的32项问卷。本报告分析了心脏病专家、内科医生和老年病医生以及初级保健医生对HF的知晓情况。71%的内科医生和老年病医生以及92%的心脏病专家使用超声心动图，43%的内科医生和老年病医生以及82%的心脏病专家将超声多普勒作为常规诊断测试（两者P<0.0001）。相比之下，75%的初级保健医生使用体征和症状来诊断HF。在内科医生和老年病医生中，愿意在90%以上患者中使用血管紧张素转换酶（ACE）抑制剂的人数较少（64%对82%的心脏病专家，P<0.0001），而只有47%的初级保健医生会常规开具ACE抑制剂。35%的初级保健医生认为HF恶化是ACE抑制剂治疗的风险。内科医生和老年病医生以及初级保健医生一直未按照目标剂量开具ACE抑制剂（与心脏病专家相比，P<0.0001）。只有39%的内科医生和老年病医生会在50%以上患者中使用β受体阻滞剂（与73%的心脏病专家相比，P<0.0001）。此外，只有5%的初级保健医生会始终开具β受体阻滞剂，35%的初级保健医生经常开具，且只有7%-29%的患者能达到目标剂量。此外，在已经服用ACE抑制剂且正在服用利尿剂的轻度HF患者中，34%的初级保健医生和26%的内科医生和老年病医生不会起始使用β受体阻滞剂，而心脏病专家中这一比例为11%（P<0.0001）。在轻度、稳定的HF患者中，39%的初级保健医生和18%的内科医生和老年病医生只会开具利尿剂，而心脏病专家中这一比例为7%（P<0.0001）。在窦性心律且服用最佳剂量ACE抑制剂、β受体阻滞剂和利尿剂的HF恶化患者中，显著更多的心脏病专家会加用螺内酯，但内科医生和老年病医生更常加用地高辛。
尽管每个医生群体都未完全遵循指南推荐的管理策略，但内科医生、老年病医生和初级保健医生对这些策略的使用明显较差，这表明需要对这些重要的医疗保健提供者进行教育。
