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Original research article
Routes to diagnosis of heart failure: observational study using linked data in England
  1. Alex Bottle1,
  2. Dani Kim1,
  3. Paul Aylin1,
  4. Martin R Cowie2,
  5. Azeem Majeed1,
  6. Benedict Hayhoe1
  1. 1 Department of Primary Care and Public Health, Imperial College London, London, UK
  2. 2 National Heart and Lung Institute, Imperial College London, London, UK
  1. Correspondence to Dr Alex Bottle, Department of Primary Care and Public Health, Imperial College, London, UK; robert.bottle{at}


Objective Timely diagnosis and management of heart failure (HF) is critical, but identification of patients with suspected HF can be challenging, especially in primary care. We describe the journey of people with HF in primary care from presentation through to diagnosis and initial management.

Methods We used the Clinical Practice Research Datalink (primary care consultations linked to hospital admissions data and national death registrations for patients registered with participating primary care practices in England) to describe investigation and referral pathways followed by patients from first presentation with relevant symptoms to HF diagnosis, particularly alignment with recommendations of the National Institute for Health and Care Excellence guideline for HF diagnosis.

Results 36 748 patients had a diagnosis of HF recorded that met the inclusion criteria between 1 January 2010 and 31 March 2013. For 29 113 (79.2%) patients, this was first recorded in hospital. In the 5 years prior to diagnosis, 15 057 patients (41.0%) had a primary care consultation with one of three key HF symptoms recorded, 17 724 (48.2%) attended for another reason and 3967 (10.8%) did not see their general practitioner. Only 24% of those with recorded HF symptoms followed a pathway aligned with guidelines (echocardiogram and/or serum natriuretic peptide test and specialist referral), while 44% had no echocardiogram, natriuretic peptide test or referral.

Conclusions Patients follow various pathways to the diagnosis of HF. However, few appear to follow a pathway supported by guidelines for investigation and referral. There are likely to be missed opportunities for earlier HF diagnosis in primary care.

  • heart failure
  • electronic medical records
  • health care delivery
  • quality and outcomes of care

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  • Contributors AB, DK and BH conceived and designed this study. AB and DK prepared the data; DK carried out the analysis, overseen by AB and BH. All authors took part in interpreting the data for this study, commented on and helped to revise drafts of this paper and have approved the final version. AB is the guarantor.

  • Funding The Dr Foster Unit at Imperial College London is partially funded by a grant from Dr Foster, a Telstra Health private healthcare information company. The Dr Foster Unit at Imperial College London is partly funded by research grants from the National Institute for Health Research Health Services Research. Prof Cowie’s salary is supported by the NIHR Cardiovascular Biomedical Research Unit at the Royal Brompton Hospital, London.

  • Ethics approval ISAC of CPRD; we also have LREC approval from NRES London – South East committee.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Due to information governance rules applicable to CPRD, no data are available for sharing.

  • Correction notice Since this paper was first published online an acknowledgements statement has been added.