The full National Heart Failure Audit report[1] and a recent editorial in the Lancet endorse the report's conclusion that it 'provides a powerful incentive to reorganize heart failure care in the UK'.[1,2] The suggested solution is to provide specialist care similar to that given to people after heart attacks citing that such specialized units 'could do for heart failure what coronary care units have done for myocardial infarction.'[2] There is no mention of how primary care could be involved and there is only a passing reference to rehabilitation. Since 2004 general practitioners in the UK have been rewarded for maintaining heart failure registers through the quality and outcomes framework of the GMS contract. In many parts of the UK there are community based heart failure specialist nurses who make an important contribution in caring for patients with heart failure - providing lifestyle advice and supervising the gradual titration of beneficial drugs such as angiotensin converting inhibitors and beta blockers. It would make sense to link these community-based services with the services in hospitals. The forward in the audit report acknowledges that 'it is vital that there is close collaboration between primary and secondary care if the improved outlook for heart failure patients is to be realised'. [1] The benefits of nurse led secondary prevention clinics for coronary heart disease in primary care are proven[3]and a recent updated Cochrane review of exercise in heart failure has demonstrated improved outcomes.[4] It is possible to link clinics in primary care with cardiac rehabilitation programmes [5] and commissioners can now access new NHS support for cardiac rehabilitation to design better services for heart failure.(http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/Browsable/DH_117504)

Hasnain Dalal, Peninsula Medical School (Primary Care), Truro, TR1 3HD Jenny Wingham, Royal Cornwall Hospitals Trust, Truro Patrick Doherty, York St John University Robert JP Lewin, University of York, York Rod S Taylor,Penisula Medical School(Primary Care), Exeter

Reference List

(1) NHS Information Centre and the British Society for Heart Failure. National Heart Failure Audit 2010. 2010. Ref Type: Report

(2) Crunch time for heart failure care in England and Wales. Lancet 2010; 376(9758):2041.

(3) Campbell NC, Thain J, Deans HG, Ritchie LD, Rawles JM, Squair JL. Secondary prevention clinics for coronary heart disease: randomised trial of effect on health. BMJ 1998; 316(7142):1434-1437.

(4) Davies EJ, Moxham T, Rees K, Singh S, Coats AJ, Ebrahim S et al. Exercise training for systolic heart failure: Cochrane systematic review and meta-analysis. Eur J Heart Fail 2010; 12(7):706-715.

(5) Dalal HM, Evans PH. Achieving national service framework standards for cardiac rehabilitation and secondary prevention. BMJ 2003; 326(7387):481-484

Conflict of Interest:

All authors except Patrick Doherty are members of the REACH HF Study Group which has received funding from the NIHR as a Programme Development Grant to conduct research in heart failure and cardiac rehabilitation

Remarkably, chest radiography was notable by its absence from the "mandatory fields for completion" in the 2008-2009 national heart failure audit(1) notwithstanding the documentation that clinical markers of congestion have high positive predictive value(PPV) for validation of acute heart failure(2). According to one review, pulmonary vascular redistribution is associated with a PPV of 75% and a negative predictive value(NPV) of 52% for the presence of acute heart failure. Correspondingly, interstitial oedema is associated with PPV and NPV of 78% and 53%, respectively(2). Accordingly the national heart failure audit was a missed opportunity for evaluating the diagnostic accuracy of these two radiographic parameters in the real world References (1) Cleland JG., McDonagh T., Rigby AS et al The national heart failure audit for England and Wales 2008-2009 Heart 2011;97:876-886 (2)Gheorghiade M., Follath F., Ponikowski P et al Assessing and grading congestion in acute heart failure: a scientific statement from the Acute Heart Failure Committee of the Heart Failure Association of the European Society of Cardiology and Endorsed by the European Society of Intensive Care Medicine European Journal of Heart Failure 2010;12:423-33

Conflict of Interest:

None declared