Sometimes the Cardio Ward Is Best

A new study out of England finds that, for heart-failure patients, being admitted to the general ward instead of the cardiology ward can mean death: “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.” Fewer heart failure patients in general wards were given echocardiograms, but patients in both types of wards experienced “sub-optimal” care. “‘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.” [%comments]


crquack

Good luck with all that outside major centres. What is the waiting list for an echocardiogram in UK?

Most non-cardiologists have difficulty *diagnosing* heart failure let alone treating it. Some of those who like to pass for cardiologists actually do not have cardiology qualifications.

The picture is not pretty...

Nick

@crquack - if you'd looked at the link you'd see that 75% of the 6000 patients in the study were given an echocardiogram, more than those who showed breathlessness or swollen feet or ankles. This suggests waiting lists weren't an issue.

crquack

The article does not state *when* the echo was performed. One is lead to believe by implication that this happened during the admission, however, this may not have been the case. Often the practice is to book the echo "as an outpatient" - with a variable waiting period.

The second issue is the quality of echo. This is highly operator dependent, both from the technical and from the interpretive standpoint. Not recording ejection fraction in a patient referred with heart failure is a major omission although the details again might be missing. Often EF is recorded as "normal" if clearly over 60%. There are other causes of heart failure than low EF.

Neither breathlesness nor swollen ankles are diagnostic of heart failure. Both have a fairly broad differential diagnosis. Either was present in less than half of the admitted patients. Thus one has to wonder how the diagnosis of heart failure was made.

Natriuretic peptide which, incidentally, has also certain issues, would be a good test if interpreted correctly. However, local experience suggests that this test was not available or restricted for cost reasons in 2006/7. This would more likely be the case in UK than in Canada. The test was ordered in only a small minority of patients, even those admitted to cardiology wards.

The truth is that heart failure management is a process which is time-consuming and skillful, both from medical and nursing point of view (careful daily weighing and fluid balance monitoring to mention but two). In UK the medical part is often delegated to doctors in training, some with very little experience or supervision. Such supervision might be less than optimal if the patient was admitted under a non-cardiology "firm". Thus the results of the study are completely consistent but will be difficult to rectify.

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