Author + information
- Received December 9, 1996
- Revision received April 21, 1997
- Accepted April 21, 1997
- Published online August 1, 1997.
- ↵*Dr. Barry M. Massie, Cardiology Section (111-C), Veterans Affairs Medical Center, 4150 Clement Street, San Francisco, California 94121.
Objectives. This study was designed to characterize physician practices in the management of congestive heart failure (CHF) and to determine whether these practices vary by specialty and how they relate to guideline recommendations.
Background. Congestive heart failure is responsible for considerable mortality, morbidity and health care resource utilization. Although there have been important advances in the diagnostic evaluation and treatment of CHF, little information is available on physician practices in this area.
Methods. We surveyed physicians concerning their management of patients with CHF. The results were analyzed in multivariate models to determine the relation of diagnostic and treatment approaches to physician specialty, time since training, board certification and volume of patients with CHF. Surveys were sent to a sample of 2,250 family and general practitioners (FP/GPs), internists and cardiologists. Responses were examined in relation to guidelines issued by the Agency for Health Care Policy and Research that had been released 9 months previously.
Results. Significant differences were found between physician groups with regard to each of the major guideline recommendations. For example, routine evaluation of left ventricular function, a point of emphasis in the guideline, is performed by 87% of cardiologists, but by only 77% of internists and 63% of FP/GPs (p < 0.001 between groups). Angiotensin-converting enzyme inhibitors were used by cardiologists, internists and FP/GPs in 80%, 71% and 60% of patients with mild to moderate CHF, respectively (p < 0.001 between groups). Larger differences were reported in the prescribed dosages of these drugs and their use in patients with renal dysfunction.
Conclusions. Cardiologists report practices more in conformity with published guidelines for CHF than do internists and FP/GPs. Because of the large numbers of patients with CHF and their substantial mortality, morbidity and cost of care, these differences may have a major impact on outcomes and health care costs.
Congestive heart failure (CHF) is a major cause of morbidity and mortality, affecting an estimated 4.7 million individuals, with 470,000 new cases reported each year, and resulting in 875,000 hospital admissions in 1993 [1, 2]. It has been estimated that the annual cost of managing patients with CHF exceeds $10 billion [3, 4]. Although mortality rates from most cardiovascular diseases have been falling [1, 5], this has not been the case for CHF [1, 6]. These trends continue despite important advances in therapy, particularly with regard to the ability of angiotensin-converting enzyme (ACE) inhibitors to prolong survival and prevent hospitalization [7–10]. However, despite extensive publicity concerning these results and the publication of practice guidelines by the Agency for Health Care Policy and Research (AHCPR) in 1994 , it is uncertain to what extent these advances have been implemented into clinical practice. Indeed, the first area for future research recommended by the AHCPR panel was that pertaining to the question, “What are the current practice patterns for patients with heart failure?” .
Previous studies have reported differences in clinical practices between generalists and specialists with regard to treating several common conditions [11–15], including unstable angina pectoris and myocardial infarction [16–19]. Although most patients with CHF are managed by generalists rather than cardiologists , CHF is a complex problem, with a high rate of treatment failures and rehospitalizations , and therefore may be more optimally managed with the guidance of specialists or subspecialists. Therefore, the present study was undertaken to survey the practices of family and general practitioners (FP/GPs) internists and cardiologists with regard to the diagnosis, assessment and treatment of patients with CHF and to compare these responses to the guidelines of the AHCPR, which were published 9 months earlier.
1.1 Study group and sample size.
To compare the self-reported practices of these three groups of physicians, it was estimated that responses from 250 physicians in each group were required to achieve an 80% power (beta error 0.20) to detect 10% absolute intergroup differences with an alpha error of 0.05 (adjusted for multiple comparisons). Assuming a minimal response rate of 40% and an undeliverable rate of 20%, surveys were mailed to 750 practitioners from each group. This sample was randomly selected from the American Medical Association’s Physician Masterfile. To maximize the comparability of the three groups, they were stratified for geographic distribution into four regions (East, Midwest, South and West) and required to have a practice in a town or city with at least 100,000 inhabitants. Physicians >65 years of age were excluded, as were physicians within 5 years of graduation.
1.2 Survey instrument.
A questionnaire was developed specifically for this study. The items analyzed for this study are included in the Appendix A. This survey was keyed to the major points of the AHCPR guidelines (Table 1) so that the results could be evaluated in reference to these evidence-based recommendations. Information was sought concerning 1) the characteristics of the respondents and their practices, including board certification, year of completion of training, number of patients with CHF seen and practice setting; 2) the testing procedures used in the diagnosis, assessment and follow-up of patients with CHF; and 3) the approaches to initiating and adjusting pharmacologic therapy. To provide a common reference from which to answer the questions related to treatment, CHF was stated to be caused by left ventricular systolicdysfunction (left ventricular ejection fraction ≤40%), and patients were described as having “mild to moderate heart failure,” defined as stable ambulatory outpatients with symptoms only on moderate exertion, or “severe, often unstable heart failure,” defined as a patient with symptoms occurring sometimes at rest. Response options were multiple choice or check-boxes.
1.3 Conduct of survey.
The timing of the survey distribution (March 1995) was to start 9 months after the release of the AHCPR guidelines. A reminder postcard was sent to all physicians 10 days after the original mailing. After 21 days, nonresponders were contacted by telephone to confirm their address and encourage them to respond. After 28 days, a second survey was sent by priority mail to nonresponding physicians whose addresses could be confirmed. An independent survey research firm (Freeman, Sullivan and Company) coordinated the mailings and performed the telephone contacts.
1.4 Data analysis.
Univariate analyses were performed to compare the responses of the physician groups. If the variable was binary, the chi-square statistic was used. Because of the multiple comparisons, a threshold of p = 0.01 was set for statistical significance. If the overall p value was <0.01, then pairwise comparisons were done. For continuous variables, differences were examined using nonparametric statistics (Kruskal-Wallis test); if the p value was <0.01, then pairwise comparisons were performed.
To determine whether medical specialty was an independent predictor of the responses, other possible determinants, such as year of training completion, board certification and number of patients with CHF, were examined and controlled for in multivariate analyses. For binary variables, multiple logistic regression was used, and for continuous variables, a general linear model was used. Analyses were performed with SAS version 6 statistical software (SAS Institute). In multivariate analyses, p = 0.05 was set as the threshold for statistical significance.
2.1 Response rate to survey.
Of 2,250 surveys mailed, 65 were sent to physicians who were deceased or retired and 396 were undeliverable at the addresses provided and could not be traced by telephone. Of the remaining 1,789 valid names, 994 (55.6%) returned the questionnaire. This figure includes 342 (58.6%) of 584 FP/GPs, 325 (55.8%) of 582 internists and 327 (52.7%) of 621 cardiologists. Sixty responding physicians were not included in the final analysis, based on predetermined criteria of not seeing at least one patient with CHF per week (n = 42) or of not completing the entire survey (n = 18), leaving a total of 934 subjects. These were approximately evenly distributed between the FP/GPs, internists and cardiologists (Table 2).
2.2 Characteristics of survey responders.
Some of the salient characteristics of the responding physicians are included in Table 2. The median year of training completion and geographic distribution were similar in the three groups. The proportion of physicians certified in their area of practice increased with the degree of specialization. Although the great majority of FP/GPs (72%) were primarily office-based, most cardiologists were primarily hospital-based in their practice and cardiologists saw more patients with heart failure on a weekly basis. The nonresponders were similar to the responders with regard to specialty, gender and geographic distribution.
2.3 Diagnostic evaluation of patients with CHF.
Several questions were used to evaluate the use of diagnostic tests in patients with CHF (Table 3): FP/GPs (73%) and internists (68%) reported using X-ray films to establish the diagnosis of CHF more often than did cardiologists (47%), whereas cardiologists indicated that they were more likely to use an echocardiogram in making the initial diagnosis (48% vs. 15% for FP/GPs and 22% for internists). Cardiologists reported assessing left ventricular function in a higher proportion of their CHF patients (92% vs. 69% by internists and 61% by FP/GPs). Echocardiography was the primary modality for evaluating left ventricular function. The reported utilization of several other tests is also included in Table 3. Cardiologists were more likely to perform stress tests and cardiac catheterization. If only patients who were considered appropriate candidates for revascularization and those who had angina are considered, >90% of physicians in each group indicated that they would order a stress test or coronary angiogram or refer the patient to a specialist for further evaluation (data not shown). Of note, the generalists rarely obtained cardiology consultations as part of their initial evaluation of patients with CHF.
2.4 Treatment of patients with CHF.
The responses to questions concerning CHF treatment are shown in Table 4and Fig. 1and Fig. 2. Even in mild CHF, only a minority of physicians in each group indicated that they used a single drug as their initial therapeutic approach. However, among these, FP/GPs reported more use of diuretic agents; internists were evenly split between a diuretic agent and ACE inhibitor; and cardiologists were more likely to use an ACE inhibitor. Sixty-two percent, 65% and 68% of the FP/GPs, internists and cardiologists, respectively, indicated that combination therapy was their initial approach (p = NS), but cardiologists claimed a higher rate of prescribing three drugs (diuretic agents, ACE inhibitors and digoxin) in combination. The percentage of FP/GPs who reported using ACE inhibitors, either alone or in combination with other medications, as part of their initial regimen was significantly lower (60%) than that for internists (74%) or cardiologists (85%) (Fig. 1). During maintenance therapy, there were similar trends for the use of ACE inhibitors, which were reported to be prescribed in 80% of patients by cardiologists, 71% by internists and 60% by FP/GPs. Cardiologists also indicated significantly higher utilization of digoxin, nitrates, hydralazine and beta-blockers in their patients with mild to moderate CHF.
In patients with severe CHF, cardiologists indicated that they were more likely to commence with a three-drug regimen of a diuretic, ACE inhibitor and digoxin (71%) than FP/GPs (51%) and internists (54%). An ACE inhibitor was included in the initial regimen in 95% of the patients seen by cardiologists, which was significantly more frequent than the use in patients seen by internists and FP/GPs (82% and 77%), respectively. Cardiologists also reported greater use of diuretic agents, ACE inhibitors, digoxin, nitrates, hydralazine and beta-blockers.
Of note, this variation among physician groups with regard to the use of ACE inhibitors occurred despite the fact that the vast majority of FP/GPs, internists and cardiologists (91%, 92% and 98%, respectively) indicated awareness of clinical trials demonstrating improved survival with ACE inhibitor therapy in patients with CHF.
2.5 Differences in approaches to using ACE inhibitors.
In addition to using ACE inhibitors more frequently, cardiologists reported prescribing them in higher dosages. These differences appear to stem from very different approaches to titrating ACE inhibitors (Fig. 2). Although 74% of FP/GPs and 55% of internists said they use the lowest dose producing an adequate symptom response, 78% of cardiologists advance to a higher dose level unless the drug is not tolerated. Abnormal renal function is one factor more likely to preclude the use of ACE inhibitors by FP/GPs. Sixty-six percent of FP/GPs would not use ACE inhibitors if the creatinine level is ≥2.5 mg/dl, compared with 34% of cardiologists, with internists falling in between (47%).
Cardiologists also reported using ACE inhibitors more frequently in patients known to have asymptomatic left ventricular dysfunction as evidenced by an ejection fraction <40% (75% vs. 55% vs. 62% for patients seen by cardiologists vs. FP/GPs vs. internists, respectively; p < 0.001).
2.6 Approach to following patients with CHF.
A plurality of physicians from each group (48% of FP/GPs, 55% of internists and 51% of cardiologists) stated that they used clinical assessment as the primary mode of following patients being treated for CHF. Of those using testing procedures, more FP/GPs and internists than cardiologists reported using chest X-ray films (31% and 27% vs. 13%, respectively), whereas more cardiologists indicated that they used echocardiography (33% vs. 16% and 15% for FP/GPs and internists, respectively).
2.7 Independent effects of time since training, board certification and volume of patients with CHF.
Because the physician groups differed significantly in their proportion of physicians indicating they were board certified in their stated field and the number of patients with CHF they had seen, and cardiologists also tended to have completed their training more recently, multivariate analyses incorporating the variables of physician group, years since completion of training, board certification and number of patients with heart failure treated per week were used to determine whether these additional factors could explain the differences among the three categories of physicians. For each survey item where differences were observed, the physician group proved to be the most significant factor, and the differences reflected the degree of specialization, with FP/GPs differing most from cardiologists, and internists falling between these two groups.
However, the year in which training was completed was an independent predictor of each of the responses where physician specialty was significant. Physicians with more recent training reported practice patterns more similar to specialists than those with more distant training. Board certification also proved to be a significant factor in the multivariate models. Board certification was independently associated with more frequent use of echocardiograms and greater use of ACE inhibitors as initial therapy and during maintenance therapy. Certified physicians also used higher doses of ACE inhibitors. In contrast, after adjusting for the other factors, the number of patients with CHF was not an independent predictor of any of these practices.
The primary findings of this study relate to the substantial differences in reported practices between physicians with different training backgrounds. These differences were present even though the survey was distributed after the dissemination of guidelines for the management of CHF , and the majority of physicians in each group expressed familiarity with the results of the clinical trials on which these guidelines were based. Furthermore, in the months before the survey, reports containing the guideline recommendations appeared in the published general medical data [22, 23]as well as in numerous closed-circulation publications. The principal recommendations of the AHCPR guidelines are summarized in Table 1, and for each of these recommendations, the present study demonstrates highly significant differences in self-reported management practices for CHF among physicians with varying degrees of specialization, with the cardiologists’ responses conforming more closely than those of the internists and FP/GPs. Of note, even within these groups, board certification was also associated with greater conformity.
The demonstrated ability of ACE inhibitors to improve prognosis in patients with CHF and asymptomatic left ventricular dysfunction represents the major recent therapeutic advance in the management of CHF. As a result, several of the guideline recommendations deal with the use of ACE inhibitors. An encouraging finding is the substantial reported use of ACE inhibitors by FP/GPs and internists in patients described as having mild to moderate CHF, both as part of their initial regimen (62% and 74%, respectively) and during maintenance therapy (60% and 71%, respectively). These figures represent a major practice shift since a survey conducted in 1984, when only 9% of physicians considered a vasodilator as first-line therapy . Even 5 years ago, only 32% of patients with the diagnosis of CHF were found to be receiving ACE inhibitors .
This increase in ACE inhibitor usage is confirmed by marketing research as well . In a study of physicians conducted just before the present survey, ACE inhibitors were reported to be used in 46%, 58%, 80% and 87% of patients with New York Heart Association functional class I, II, III and IV symptoms, respectively. Angiotensin-converting enzyme inhibitor usage by cardiologists was also higher than that for generalists, especially in patients with milder symptoms (53% vs. 44% for functional class I and 66% vs. 56% for class II). However, in the present survey, more striking than the greater reported usage of ACE inhibitors by cardiologists are the differences in the manner in which these drugs are used. The AHCPR guidelines recommend using the higher doses employed in the clinical trials demonstrating improved outcomes with ACE inhibitor therapy, because the efficacy of lower doses remains unestablished . Cardiologists indicate that they more frequently titrate their patients to the dosages proven efficacious in trials and are less reluctant to use ACE inhibitors in patients with moderate renal dysfunction.
Other differences in reported medication usage warrant comment. Cardiologists more frequently use digoxin, nitrates and hydralazine, the other agents recommended by guidelines for patients who remain symptomatic, than do generalists. Importantly, however, few physicians in any of the groups state that they use calcium channel blockers in patients with CHF, which represents a distinct improvement from earlier observations in which these agents were frequently administered [8, 25]. Differences between physician groups were also reported for the use of diagnostic tests. The greater use of echocardiograms by cardiologists in the initial evaluation of patients with CHF is consistent with the guideline recommendations for assessing left ventricular function. The greater use of stress tests and cardiac catheterization by cardiologists also is in keeping with the guideline recommendations to correct reversible causes of CHF, including myocardial ischemia. The relatively low usage of these last two tests by all three physician groups may be indicative of the nature of CHF, because these numbers are far higher when only patients who are suitable candidates for revascularization are considered.
The higher use of these tests by cardiologists is consistent with the previously reported greater use of diagnostic procedures when heart failure is managed by cardiologists and the higher resource utilization by specialists in general [15, 17, 29]. From the present data, it is impossible to speculate as to whether the self-reported use of stress testing and coronary angiography in 35% and 20% of their patients by cardiologists is appropriate or excessive. It is also noteworthy that only ∼50% of physicians in all three groups followed their patients primarily by clinical assessment, as recommended by both the AHCPR and ACC/AHA guidelines. Among the remainder, cardiologists were more likely to use echocardiograms and the FP/GPs and internists, chest X-ray films.
3.1 Study limitations.
This study has several limitations. Although the 55.6% response rate was comparable or higher than that in many previous reports [16, 24, 28], it remains possible that the results are not generalizable because of a selection bias related to the level of knowledge and comfort with treating CHF among physicians who chose to respond. The comparable proportion of respondents in the three groups and the absence of any systematic differences between the responders and nonresponders with regard to demographic variables, however, makes it reasonable to compare them.
It is also uncertain whether the responses reflect the physicians’ actual practices or are influenced by selective recall or their desire to give the “correct” answer. Several studies have highlighted the substantial discrepancies between physicians’ self-reported practices and actual performance [30, 31]. However, the similarity of the present study’s results to marketing data derived from different methods does provide some independent validation of the treatment results.
A third problem inherent in survey methodology is that the physicians may have answered the questions from a different frame of reference, because the characteristics of patients with CHF usually treated by cardiologists, internists and FP/GPs may differ. This potential problem was addressed by clearly indicating in the questionnaire that CHF was caused by left ventricular systolicdysfunction, and with regard to treatment, by asking separate questions for stable outpatients defined as having either “mild to moderate” or “severe” symptoms.
It is also important to note that these analyses were based on group mean or median data and that many generalists may have responded very similarly to some cardiologists, so it is difficult to generalize about groups of physicians. In that regard, the finding that year of training completion and board certification are significant independent correlates of the responses indicates that there is considerable heterogeneity within the physician groups.
Finally, it is crucial to emphasize that this study did not compare patient outcomes or any measure of cost-effectiveness between groups of generalists and specialists, but only their self-described practices. This is a controversial area, fraught with methodologic difficulties, and is beyond the scope of this study.
3.2 Study implications.
Several of the observed practice differences could potentially have important consequences. Without routine measurements of left ventricular function, a substantial number of patients with diastolic dysfunction might be treated with agents, such as digoxin or vasodilators, with no demonstrated benefit in this condition. The lower use of ACE inhibitors by generalists in symptomatic patients with CHF and in asymptomatic patients with left ventricular dysfunction, as well as the lower dosages used by them when ACE inhibitors are used, could have an adverse effect on morbidity and mortality from this condition. Based on the results of clinical trials of ACE inhibitors , the estimated numbers of patients with CHF in the United States and the fact that the majority of these patients are managed by generalists, the lower use of ACE inhibitors among FP/GPs and internists might translate into several thousand avoidable deaths and many more preventable hospital admissions.
These results raise several important questions. First, can the practice patterns of the generalists be changed to make them more consistent with guideline recommendations? The rising proportion of patients receiving ACE inhibitors suggests that progress is being made, but that it is slow and incomplete. In that regard, it is noteworthy that only 41% of the FP/GPs and 39% of the internists, compared with 59% of cardiologists, indicated familiarity with the AHCPR guidelines, which had been published 9 months earlier. A search for articles covering the guideline material or review articles on the management of CHF published in the 1993–1994 period uncovered only six such reports in internal medicine, family and general practice and geriatric journals published in the United States and listed in Index Medicus[23, 24, 32–35]. Nearly four times that number were published in the four major cardiology journals published in the United States. Thus, the necessary information may not have been disseminated adequately to the groups least familiar with it. This may explain the longer time lag between the incorporation of new evidence-based recommendations into the practices of generalists and specialists, and it also suggests that smaller differences might be observed if this survey were to be repeated after several years.
Even when appropriate information on new advances and practice guidelines is provided, however, more direct interactive communication may be required to change practice patterns . Continuing medical education programs have also had limited effectiveness in changing physician practices . More innovative approaches should be considered .
The significant independent effect of time since completion of training is instructive. It would appear that physicians who are more recently out of training are more likely to be familiar with and incorporate new advances into their practices. Clearly, the challenge of remaining current in a wide spectrum of evolving clinical practices is a difficult one, and it is not surprising that specialists and subspecialists have an advantage in their own fields.
This raises the question of whether cardiologists should be more actively involved in managing of patients with CHF. Current practice patterns and the trend toward more of a “gatekeeper” role for generalists make it unlikely that all patients with CHF will be followed by cardiologists, nor is there evidence that doing so would improve their outcome. However, it may not be unreasonable for many such patients to be evaluated by a specialist and for a cardiologist to be involved in the management of those with more severe CHF. This latter group is responsible for a disproportionate number of deaths and resource utilization. In that regard, recent studies have demonstrated that aggressive multidisciplinary programs under the supervision of a specialist can prevent rehospitalization of patients discharged with the diagnosis of CHF and result in a net cost savings [39, 40].
The present study is not unique in demonstrating potentially important differences between specialists and generalists. Previous studies have shown differences in treatment approaches of cardiologists and generalists in the management of unstable angina pectoris and myocardial infarction [16–19]. These results, and those in other subspecialty areas [13–15], raise the possibility that optimal management of some patients with diseases for which practices are evolving rapidly and which result in substantial mortality, morbidity and resource utilization may include consultation or continuing involvement by specialists. However, in the current climate of aggressive cost reduction, improvements in outcomes and cost-effectiveness will be required to support this conclusion .
We express our gratitude to Drs. David Baker, Stephen McPhee, Kevin Grumbach, Andrew Bindman and Lee Goldman for their review of this manuscript and their helpful comments and suggestions.
A.1 Questions Used in Analysis
1.1. Excluding the history and physical examination, what is the most common primary modality you use to establish the diagnosis of heart failure? (Select one.)
A. I do not use additional testing in the majority of my patients
B. Chest X-ray film
D. Nuclear medicine test of left ventricular function
E. Right heart catheterization
F. Cardiac catheterization including coronary angiography
G. I refer the patient for further evaluation
1.2. In new patients with symptoms of heart failure, in what percentage of your patients do you order the following procedures as part of your initial evaluation? Note, for this purpose the initial evaluation is defined as procedures or tests ordered together or sequentially in confirming the diagnosis. (Indicate percent. Total may exceed 100%.)
A. Referral to a consultant %
B. Echocardiogram %
C. Chest X-ray film %
D. Stress test (exercise or pharmacologic) to detect ischemia %
E. Electrocardiogram %
F. Nuclear medicine test of left ventricular function %
G. Cardiac catheterization and coronary angiography %
1.3. In what percentage of patients with newly diagnosed heart failure do you assess left ventricular systolic function(by echocardiography, nuclear medicine or cardiac catheterization)? %
Many classes of medications have been demonstrated to be useful in heart failure, and there is no single standard treatment approach. In the following section please indicate your current practice in the treatment of heart failure in patients with left ventricular systolic dysfunction (ejection fraction <40%). (Questions 4 and 5 refer to patients with mild to moderate heart failure, defined as a stable ambulatory outpatient with symptoms only on moderate exertion. Questions 6 and 7 refer to patients with severe, often unstable heart failure, defined as a patient with symptoms occurring sometimes at rest.)
2.1. In your patients with mild to moderate heart failure in normal sinus rhythm, what is your usualchoice of treatment for first-line therapy? First-line therapy is defined as a single initial medication or a combination of medications that may be started together or as a planned sequence. (Select the single best answer.)
A. Diuretic agent
B. ACE inhibitor
D. Diuretic agent plus an ACE inhibitor
E. Diuretic agent plus digoxin
F. ACE inhibitor plus digoxin
G. Diuretic agent plus ACE inhibitor plus digoxin
2.2. In your patients with mild to moderate heart failure, what percentage are taking eachof the following drugs solelyfor the indication of heart failure (i.e., not for angina or hypertension)? (Please indicate the percentage of your patients on the following drugs. Enter zero if you do not use a particular medication.)
A. Diuretic agents %
B. ACE inhibitors %
C. Digoxin %
D. Nitrates %
E. Hydralazine %
F. Beta-blockers %
G. Calcium channel blockers %
2.3. In your patients with severe heart failure in normal sinus rhythm, what is your usualchoice of treatment for first-line therapy? First-line therapy is defined as a single initial medication or a combination of medications that may be started together or as a planned sequence. (Select the single best answer.)
A. Diuretic agent
B. ACE inhibitor
D. Diuretic agent plus ACE inhibitor
E. Diuretic agent plus digoxin
F. ACE inhibitor plus digoxin
G. Diuretic agent plus ACE inhibitor plus digoxin
2.4. In your patients with severe heart failure, what percentage are taking eachof the following drugs solelyfor the indication of heart failure (i.e., not for angina or hypertension)? (Please indicate the percentage of your patients on the following drugs. Enter zero if you don’t use a particular medication.)
A.Diuretic agents %
B. ACE inhibitors %
C. Digoxin %
D. Nitrates %
E. Hydralazine %
F. Beta-blockers %
G. Calcium channel blockers %
2.5. In all of your patients with heart failure who are taking an ACE inhibitorfor the treatment of left ventricular systolic dysfunction, what percentage are taking low dose, medium dose and high dose therapy as defined below? (Total should equal 100%.)
A. Low dose (captopril or Capoten <50 mg/day total; enalapril or Vasotec ≤5 mg/day total; lisinopril or Prinivil or Zestril ≤5 mg/day total; quinapril or Accupril ≤10 mg/day total or the equivalent) %
B. Medium dose (captopril 50 to 75 mg/day total; enalapril 6 to 15 mg/day total; lisinopril 6 to 15 mg/day total; quinapril 11 to 20 mg/day total or the equivalent) %
C. High dose (captopril >75 mg/day total; enalapril >15 mg/day total; lisinopril >15 mg/day total; quinipril >20 mg/day total or the equivalent) %
2.6. In a patient taking an ACE inhibitorfor the treatment of heart failure who does not develop side effects, what do you consider your usual “target” dose to be? (Select the single best answer.)
A. The lowest dose producing an adequate symptomatic response?
B. A medium dose (as defined in Question 8), even if the patient has responded to a lower dose?
C. A high dose (as defined in Question 8), even if the patient has responded to a lower dose?
2.7. Is there a threshold of baseline decreased renal functionthat would prevent you from using an ACE inhibitor initially? (Select the single best answer.)
A. Creatinine ≥1.5 mg/dl
B. Creatinine ≥2.0 mg/dl
C. Creatinine ≥2.5 mg/dl
D. Creatinine ≥3.0 mg/dl
E. A higher threshold
2.8. What percentage of your patients with asymptomatic left ventricular systolic dysfunction(ejection fraction <40%) do you treat with an ACE inhibitor? %
3.1. What is your primary modality in following clinically stable patients with heart failure? (Select the single best answer.)
A. History and physical examination only
B. Chest X-ray film
C. Exercise tolerance test
E. Nuclear ejection fraction
↵3 Dr. Edep is currently a Cardiology Fellow at the University of California, San Diego, California.
↵1 This work was supported in part by unrestricted grants from Bristol-Myers Squibb Co., Princeton, New Jersey; Burroughs Wellcome Co., Research Triangle Park, North Carolina; Merck & Co., West Point, Pennsylvania; and the Department of Veterans Affairs Research Service.
↵2 All editorial decisions for this article, including selection of referees, were made by a Guest Editor. This policy applies to all articles with authors from the University of California in San Francisco.
- angiotensin-converting enzyme
- Agency for Health Care Policy and Research
- congestive heart failure
- family and general practitioners
- Received December 9, 1996.
- Revision received April 21, 1997.
- Accepted April 21, 1997.
- The American College of Cardiology
- American Heart Association
- National Center for Health Statistics, Graves EJ. 1993 Summary. National Hospital Discharge Survey. Vital Health Stat  No. 121. Hyattsville (MD), 1995:1–63.
- ↵Konstam MA, Dracup K, Baker DW, et al. Heart failure: evaluation and care of patients with left-ventricular systolic dysfunction. Rockville (MD): Agency for Health Care Policy and Research. Publication no. 94-0612, June 1994.
- Centers for Disease Control
- American College of Cardiology/American Heart Association Committee on Evaluation and Management of Heart Failure
- Schreiber TL,
- Elkhatib A,
- Grines CL,
- O’Neill WW
- Borowsky SJ, Kravitz MD, Laouri M, et al. Effect of physician specialty on use of necessary coronary angiography. J Am Coll Cardiol 1995:1484–91.
- ↵National Center for Health Statistics. National Ambulatory Medical Care Survey, 1989 Summary. Vital Health Stat  No. 110. Hyattsville (MD): Department of Health and Human Services, 1992; Publication no. 92-1774.
- Kannel WB,
- Ho K,
- Thom T
- Hlatky MA,
- Fleg JL,
- Hinton PC,
- et al.
- Young JB,
- Weiner DH,
- Yusuf S,
- et al.
- ↵(1994) Congestive Heart Failure Study VI (Market Measures, Livingston (NJ)).
- Packer M
- McPhee S,
- Richard RJ,
- Solkowitz SN
- Harlow SD,
- Linet MS