Perpech N B, Tregubov A V, Mikhailova I E
Federal State Budgetary Educational Institution of Higher Education "Saint-Petersburg State University".
ФГБОУ ВО "Санкт-Петербургский государственный университет", Санкт-Петербург.
Kardiologiia. 2022 May 31;62(5):53-61. doi: 10.18087/cardio.2022.5.n1755.
Aim To evaluate the physician's knowledge of basic provisions of clinical guidelines for diagnosis and treatment of chronic heart failure (CHF) and to determine how the actions of physicians in their everyday clinical practice comply with these provisions.Materials and methods The study analyzed anonymous questionnaires of 185 physicians (127 cardiologists, 40 internists and general practitioners, 18 other specialists) who were trained in advanced training programs during the 2020/2021 academic year. The main part of the questionnaire included 15 questions related to the classification, diagnosis, pharmacotherapy, and the use of implantable devices in the treatment of patients with CHF.Results The results showed that internists were less than cardiologists aware of major provisions of clinical guidelines for diagnosis and treatment of CHF. However, the knowledge of cardiologists could not be considered sufficient either. 57.5% of internists and 30% of cardiologists incorrectly indicated the main echocardiographic criterion for diagnosis of CHF with reduced left ventricular ejection fraction (CHFrEF). More than 40% of internists did not consider fluid retention with development of the congestion syndrome as a mandatory condition for administration of a loop diuretic to a patient with CHFrEF. 34.6% of cardiologists and 25% of internists correctly determined the indication for the administration of mineralocorticoid receptor antagonists. 37.6% of internists and 21.1% of cardiologists incorrectly indicated the dose of spironolactone recommended for achieving the neuromodulation effect. In determining doses of angiotensin-converting enzyme (ACE) inhibitors and beta-blockers, after arriving at which it is necessary to stop their up-titration, most of the physicians preferred to be based on systolic blood pressure (SBP) rather than on symptoms of hypotension. However, among therapists there were doctors for whom the patient's well-being and clinical symptoms, and not the level of SBP, were priority factors for choosing the tactics of the treatment with ACE inhibitors and beta-blockers. Physicians of both specialties were poorly familiar with indications for cardioverter defibrillator implantation; only 14.2% of cardiologists and 5% of internists chose the correct wording of indications.Conclusion The insufficient knowledge should be considered the basis for the low adherence of doctors to guidelines for diagnosis and treatment of CHF. When developing programs for advanced training of physicians in CHF, special attention should be paid to the use of renin-angiotensin-aldosterone system inhibitors and beta-blockers with detailed discussion of the dosing principles as well as of indications for implantation and results of using cardioverter defibrillators.
目的 评估医生对慢性心力衰竭（CHF）诊断和治疗临床指南基本条款的了解程度，并确定医生在日常临床实践中的行为如何符合这些条款。
材料和方法 本研究分析了185名医生（127名心脏病专家、40名内科医生和全科医生、18名其他专科医生）的匿名问卷，这些医生在2020/2021学年参加了高级培训项目。问卷的主要部分包括15个与CHF患者的分类、诊断、药物治疗以及植入式设备的使用相关的问题。
结果 结果显示，内科医生比心脏病专家对CHF诊断和治疗临床指南的主要条款了解得更少。然而，心脏病专家的知识也不能被认为是足够的。57.5%的内科医生和30%的心脏病专家错误地指出了左心室射血分数降低的CHF（CHFrEF）诊断的主要超声心动图标准。超过40%的内科医生不认为充血综合征伴液体潴留是给CHFrEF患者使用袢利尿剂的必要条件。34.6%的心脏病专家和25%的内科医生正确确定了盐皮质激素受体拮抗剂的给药指征。37.6%的内科医生和21.1%的心脏病专家错误地指出了为实现神经调节作用推荐的螺内酯剂量。 在确定血管紧张素转换酶（ACE）抑制剂和β受体阻滞剂的剂量，即达到该剂量后需要停止滴定剂量时，大多数医生倾向于依据收缩压（SBP）而非低血压症状。然而，在内科医生中有一些医生认为，对于选择ACE抑制剂和β受体阻滞剂的治疗策略，患者的健康状况和临床症状而非SBP水平是优先考虑的因素。两个专科的医生对心脏复律除颤器植入的指征都不太熟悉；只有14.2%的心脏病专家和5%的内科医生选择了正确的指征表述。
结论 知识不足应被视为医生对CHF诊断和治疗指南依从性低的原因。在制定CHF医生高级培训项目时，应特别关注肾素 - 血管紧张素 - 醛固酮系统抑制剂和β受体阻滞剂的使用，详细讨论给药原则以及心脏复律除颤器的植入指征和使用结果。
