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Objective: To determine whether a centralised telephone intervention reduces the incidence of death or admission for worsening heart failure in outpatients with chronic heart failure., Design: Multicentre randomised controlled trial., Setting: 51 centres in Argentina (public and private hospitals and ambulatory settings)., Participants: 1518 outpatients with stable chronic heart failure and optimal drug treatment randomised, stratified by attending cardiologist, to telephone intervention or usual care., Intervention: Education, counselling, and monitoring by nurses through frequent telephone follow-up in addition to usual care, delivered from a single centre., Main Outcome Measure: All cause mortality or admission to hospital for worsening heart failure., Results: Complete follow-up was available in 99.5% of patients. The 758 patients in the usual care group were more likely to be admitted for worsening heart failure or to die (235 events, 31%) than the 760 patients who received the telephone intervention (200 events, 26.3%) (relative risk reduction = 20%, 95% confidence interval 3 to 34, P = 0.026). This benefit was mostly due to a significant reduction in admissions for heart failure (relative risk reduction = 29%, P = 0.005). Mortality was similar in both groups. At the end of the study the intervention group had a better quality of life than the usual care group (mean total score on Minnesota living with heart failure questionnaire 30.6 v 35, P = 0.001)., Conclusions: This simple, centralised heart failure programme was effective in reducing the primary end point through a significant reduction in admissions to hospital for heart failure.

Objective: To examine whether there are socioeconomic gradients in the incidence, prevalence, treatment, and follow up of patients with heart failure in primary care., Design: Population based study., Setting: 53 general practices (307,741 patients) participating in the Scottish continuous morbidity recording project between 1 April 1999 and 31 March 2000., Participants: 2186 adults with heart failure., Main Outcome Measures: Comorbid diagnoses, frequency of visits to general practitioner, and prescribed drugs., Results: 2186 patients with heart failure were seen (prevalence 7.1 per 1000 population, incidence 2.0 per 1000 population). The age and sex standardised incidence of heart failure increased with greater socioeconomic deprivation, from 1.8 per 1000 population in the most affluent stratum to 2.6 per 1000 population in the most deprived stratum (odds ratio 1.44, P = 0.0003). On average, patients were seen 2.4 times yearly, but follow up rates were less frequent with increasing socioeconomic deprivation (from 2.6 yearly in the most affluent subgroup to 2.0 yearly in the most deprived subgroup, P = 0.00009). Overall, 812 (80.6%) patients were prescribed diuretics, 396 (39.3%) angiotensin converting enzyme inhibitors, 216 (21.4%) beta blockers, 208 (20.7%) digoxin, and 86 (8.5%) spironolactone. The wide discrepancies in prescribing between different general practices disappeared after adjustment for patient age and sex. Prescribing patterns did not vary by deprivation categories on univariate or multivariate analyses., Conclusions: Compared with affluent patients, socioeconomically deprived patients were 44% more likely to develop heart failure but 23% less likely to see their general practitioner on an ongoing basis. Prescribed treatment did not differ across socioeconomic gradients.

Objectives: To compare patterns of admission to hospital and prognosis in white and South Asian patients newly admitted with heart failure, and to evaluate the effect of personal characteristics and comorbidity on outcome., Design: Historical cohort study., Setting: UK district health authority (population 960,000)., Participants: 5789 consecutive patients newly admitted with heart failure., Main Outcome Measures: Population admission rates, incidence rates for first admission with heart failure, survival, and readmission rates., Results: When compared with the white population, South Asian patients had significantly higher age adjusted admission rates (rate ratio 3.8 for men and 5.2 for women) and hospital incidence rates (2.2 and 2.9). Among 5789 incident cases of heart failure, South Asian patients were younger and more often male than white patients (70 (SD 0.6) v 78 (SD 0.1) years and 56.5% (190/336) v 49.3% (2494/5057)). South Asian patients were also more likely to have previous myocardial infarction (10.1% (n = 34) v 5.5% (n = 278)) or concomitant myocardial infarction (18.8% (n = 63) v 10.7% (n = 539)) or diabetes (45.8% (n = 154) v 16.2% (n = 817), all P < 0.001). A trend was shown to longer unadjusted survival for both sexes among South Asian patients. After adjustment for covariables, South Asian patients had a significantly lower risk of death (hazard ratio 0.82, 95% confidence interval 0.68 to 0.99) and a similar probability of death or readmission (0.96, 0.81 to 1.09) compared with white patients., Conclusions: Population admission rates for heart failure are higher among South Asian patients than white patients in Leicestershire. At first admission South Asian patients were younger and more often had concomitant diabetes or acute ischaemic heart disease than white patients. Despite major differences in personal characteristics and risk factors between white and South Asian patients, outcome was similar, if not better, in South Asian patients.

Objective: To ascertain the beliefs, current practices, and decision making of general practitioners in the diagnosis and management of suspected heart failure in primary care, with a view to identifying barriers to good care., Design: A qualitative approach using focus groups with 30 general practitioners from four primary care groups. The sampling strategy was stratified and purposive. The contents of interviews were transcribed and analysed according to the principles of "pragmatic variant" grounded theory., Setting: North east England., Results: Three categories of difficulties contribute to variations in medical practice and to the reasons why general practitioners experience difficulties in diagnosing and managing heart failure. The first is uncertainty about clinical practice, including lack of confidence in establishing an accurate diagnosis and worries about using angiotensin converting enzyme inhibitors, beta blockers, and spironolactone in patients who are often elderly and frail, with comorbidity and polypharmacy. The second is a lack of awareness of relevant research evidence in what was perceived to be a complex and rapidly changing therapeutic field. Doubts about the applicability of research findings in primary care, and fear of information overload also emerged. The third category consists of influences of individual preference and local organisational factors. Medical training, negative clinical experiences, and outside agencies influenced the behaviour of general practitioners and professional culture. Local factors included the availability of diagnostic services, resources (such as accessible cardiologists), and interactions between professionals in primary or secondary care, and they seemed to shape the practice and decision making processes in primary care., Conclusions: The national service framework for coronary heart disease stresses that the substandard care of patients with heart failure is unacceptable. This study identified barriers to be overcome across primary and secondary care in implementation strategies that are specific to the locality and multifaceted. Single strategies--for example, the provision of guidelines--are unlikely to have an impact on clinical outcomes, and new, conjoint models of care need to be explored.

Objective: To compare the illness trajectories, needs, and service use of patients with cancer and those with advanced non-malignant disease., Design: Qualitative interviews every three months for up to one year with patients, their carers, and key professional carers. Two multidisciplinary focus groups., Setting: Community based., Participants: 20 patients with inoperable lung cancer and 20 patients with advanced cardiac failure and their main informal and professional carers., Main Outcome Measures: Perspectives of patients and carers about their needs and available services., Results: 219 qualitative interviews were carried out. Patients with cardiac failure had a different illness trajectory from the more linear and predictable course of patients with lung cancer. Patients with cardiac failure also had less information about and poorer understanding of their condition and prognosis and were less involved in decision making. The prime concern of patients with lung cancer and their carers was facing death. Frustration, progressive losses, social isolation, and the stress of balancing and monitoring a complex medication regimen dominated the lives of patients with cardiac failure. More health and social services including financial benefits were available to those with lung cancer, although they were not always used effectively. Cardiac patients received less health, social, and palliative care services, and care was often poorly coordinated., Conclusions: Care for people with advanced progressive illnesses is currently prioritised by diagnosis rather than need. End of life care for patients with advanced cardiac failure and other non-malignant diseases should be proactive and designed to meet their specific needs.

Objectives: To identify doctors' perceptions of the need for palliative care for heart failure and barriers to change., Design: Qualitative study with focus groups., Setting: North west England., Participants: General practitioners and consultants in cardiology, geriatrics, palliative care, and general medicine., Results: Doctors supported the development of palliative care for patients with heart failure with the general practitioner as a central figure. They were reluctant to endorse expansion of specialist palliative care services. Barriers to developing approaches to palliative care in heart failure related to three main areas: the organisation of health care, the unpredictable course of heart failure, and the doctors' understanding of roles. The health system was thought to work against provision of holistic care, exacerbated by issues of professional rivalry and control. The priorities identified for the future were developing the role of the nurse, better community support for primary care, and enhanced communication between all the health professionals involved in the care of patients with heart failure., Conclusions: Greater consideration should be given to the care of patients dying with heart failure, clarifying the roles of doctors and nurses in different specialties, and reshaping the services provided for them. Many of the organisational and professional issues are not peculiar to patients dying with heart failure, and addressing such concerns as the lack of coordination and continuity in medical care would benefit all patients.

Numerous drugs can increase cardiac output, thereby improving tissue oxygen delivery, but often they do this at the expense of increasing myocardial oxygen demand. This may be critical when cardiac function is substantially impaired or ischaemia is the precipitating cause. Using polypharmacy to substantially improve cardiovascular status requires detailed knowledge of the pharmacodynamics and interactions of the available agents so that they may be tailored to the individual patient. In some settings combinations of inotropes and vasodilators may be desirable to minimise cardiac workload. In other instances vasopressors may be necessary to urgently restore a minimum perfusion pressure. This paper reviews the use of this group of drugs as well as the mechanical assist devices that may be used when drugs fail.