169 Delayed diagnosis of heart failure: an unmet need in primary care

Introduction Heart failure (HF) is a growing epidemic with significant morbidity and mortality, estimated to affect over half a million people in the U.K., and contributes to a large burden of cost on the NHS from frequent hospital admissions. The "HF iceberg" described in literature alludes to a substantial proportion of patients with undiagnosed or poorly controlled HF. We aim to analyse patient journeys from initial presentation, to highlight the current obstacles in achieving a diagnosis and optimising management in primary care. Methods Patient records from the HF register consisting of 77 patients were analysed from a primary care site. We screened for antecedents to the development of HF, monitored risk factor burden and measured the delay in diagnosing and managing HF. Results 77 patients with HF were included in this study (mean age: 76±11 years, 50 males). 61% (n=47) presented to primary care with first-onset HF symptoms. Of those patients, a mean of 6 months elapsed between symptom onset and specialist review, compared to 3 months in those presenting to secondary care (p<0.05). 78% (n=60) had their NT-proBNP (BNP) measured, with age-adjusted abnormal elevations found in 72% (n=43). 87% (n=68) had an echocardiogram (echo) of which 53% (n=36) had an impaired left-ventricular ejection fraction (LVEF). 44% (n=34) had a repeat BNP with 59% (n=20) having a higher second result (p<0.05). 56% (n=43) had a repeat echo; 40% (n=17) showed no LVEF improvement, whereas 9% (n=4) now had an impaired LVEF (figure 1). 66% (n=43) of patients were NYHA Class II or above. Prior to developing HF, 86% (n=66) of patients had hypertension, with 74% (n=49) having poor hypertensive control. Similarly, 64% (n=49) had dyslipidaemia, with 82% (n=40) having elevated LDL levels. Lastly, 39% (n=30) had diabetes mellitus, with 37% (n=11) having elevated HbA1c levels. All three risk factors were poorly controlled for a minimum of 1 year (figure 2). Additionally, 35% (n=27) had known coronary artery disease, 47% (n=36) had a tachyarrhythmia, 17% (n=13) had valvular disease and 7% (n=5) had chronic obstructive pulmonary disease (figure 2). Conclusions Our study showed a rising burden of HF in primary care, where most patients are symptomatic with an abnormal BNP and impaired LVEF at initial investigation, yet access to echocardiography and secondary care is often delayed by up to 6 months. This puts patients at risk of worsening HF, as disease-modifying drugs are not initiated until a diagnosis is achieved. We found that contributory antecedent risk factors remain unrecognised or uncontrolled. The lack of early intervention due to diagnostic and therapeutic inertia contributes to poor outcomes. We suggest 1) Frequent monitoring and early intervention in patients with HF risk factors in primary care. 2) An awareness campaign for patients to understand their own risk factors and recognise early signs of HF. 3) A robust national screening programme for HF in primary care, with early disease detection via rapid access to BNP and echocardiography, to prevent adverse outcomes and reduce hospital admissions. Conflict of Interest N/A