Diagnosing Heart Failure in Primary Care: Lessons from EPICA

Heart failure is common. However, the size of this population is dwarfed by the number of patients in whom the diagnosis is suspected 1. Indeed, one of the reasons that the diagnosis of heart failure is commonly missed is because so many patients who do not have this problem have symptoms or events that could be interpreted as heart failure. We all know that an easy way to conceal someone is in a large crowd. Developing diagnostic strategies for heart failure is an important and intriguing problem rendered all the more difficult by the lack of a single robust diagnostic test. Epidemiological studies of heart failure have, until recently 2-5, mainly been confined to the United States of America and North-West Europe 6. The four papers from the EPICA study 7-10 together with the main paper published previously 11 make an important contribution to the diagnosis and epidemiology of heart failure. The papers are of international significance as well as providing specific information on the Portuguese population. The analysis of the value of heart failure questionnaires and their concordance I regard of particular value 7 since there are so few data on this topic from large populations. Table 1 provides the criteria used in these questionnaires to supplement the paper 12. The paper on the diagnostic value of the ECG and chest X-ray is probably the largest study of its kind and provides robust evidence upon which to base decision making 9. The paper on the treatment of heart failure shows that standards of care for heart failure in Portugal, like other nations belonging to the ESC, are sub-optimal 8. This can be achieved only by a structural change in the organisation of care for these patients. The authors are to be complimented for their contribution to medical science that will help plan better care for patients and for their careful analysis. They are to be admired even more for having the inspiration, dedication and teamwork to allow them to bring a national project of such enormous dimensions to fruition with an efficient use of limited resources. Well done!