Questions for further study
Despite these concerns, the results of the study by James et al are encouraging. Once the diagnosis of heart failure has been objectively confirmed, the treatment rate with pharmacologic agent of choice—ACE inhibitors—is high. However, many questions remain about the management of heart failure and the quality of care that can be provided by primary care physicians. Are ACE inhibitors truly the drugs of choice for all patients with heart failure or only for those with systolic dysfunction? Are angiotensin-receptor blockers comparable with ACE inhibitors in regard to the beneficial effects they produce? Does one or both of these agents reverse ventricular hypertrophy in the group of patients with heart failure from pure diastolic dysfunction? Should ACE inhibitors and angiotensin-receptor blockers be combined for optimal management of patients with more severe heart failure? Future studies should explore the role of other drugs in the management of patients with heart failure. Quality of care assessment will need to await determination of optimal treatment regimens. Recent developments call into question standard practice.6 For example, there is no consensus on whether digoxin is still indicated for patients in sinus rhythm with systolic dysfunction heart failure. Should patients with systolic dysfunction heart failure now be started routinely on b-blockers? And if so, at what point in the evolution of the disease? Should b-blockers be added early (ie, for patients with class I or class II heart failure and only minimal symptoms), or should they only be used as a last resort after ACE inhibitors, diuretics, and digoxin have all been tried? And, most recently, the question has been raised whether spironolactone should now be added to the regimen for treatment of heart failure as an adjunctive mortality-reducing measure, in an attempt to further inhibit aldosterone (beyond the effect produced by ACE inhibition) and maintain optimal electrolyte balance (potassium- and magnesium-retaining action).
Family physicians play a major role in recognizing the early signs and symptoms of heart failure, and providing continuity of care. The article by James and colleagues represents a beginning of the accumulation of data and assessment of quality control in the management of heart failure in primary care. Further work in the ambulatory primary care setting is now needed as we search for more answers.