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Original research article
Adherence to guidelines in management of symptoms suggestive of heart failure in primary care
  1. Benedict Hayhoe1,
  2. Dani Kim1,2,
  3. Paul P Aylin1,2,
  4. F Azeem Majeed1,
  5. Martin R Cowie3,
  6. Alex Bottle1,2
  1. 1 Department of Primary Care and Public Health, Imperial College London, London, UK
  2. 2 Dr Foster Unit, Department of Primary Care and Public Health, Imperial College London, London, UK
  3. 3 National Heart & Lung Institute, Imperial College London, London, UK
  1. Correspondence to Dr Benedict Hayhoe, Department of Primary Care and Public Health, Imperial College London, London W6 8RP, UK; b.hayhoe{at}


Objective Clinical guidelines on heart failure (HF) suggest timings for investigation and referral in primary care. We calculated the time for patients to achieve key elements in the recommended pathway to diagnosis of HF.

Methods In this observational study, we used linked primary and secondary care data (Clinical Practice Research Datalink, a database of anonymised electronic records from UK general practices) between 2010 and 2013. Records were examined for presenting symptoms (breathlessness, fatigue, ankle swelling) and key elements of the National Institute for Health and Care Excellence-recommended pathway to diagnosis (serum natriuretic peptide (NP) test, echocardiography, specialist referral).

Results 42 403 patients were diagnosed with HF, of whom 16 597 presented in primary care with suggestive symptoms. 6464 (39%) had recorded NP or echocardiography, and 6043 (36%) specialist referral. Median time from recorded symptom(s) to investigation (NP or echocardiography) was 292 days (IQR 34–844) and to referral 236 days (IQR 42–721). Median time from symptom(s) to diagnosis was 972 days (IQR 337–1468) and to treatment with HF-relevant medication 803 days (IQR 230–1364). Factors significantly affecting timing of referral, treatment and diagnosis included patients’ sex (p=0.001), age (p<0.001), deprivation score (p=0.001), comorbidities (p<0.001) and presenting symptom type (p<0.001).

Conclusions Median times to investigation or referral of patients presenting in primary care with symptoms suggestive of HF considerably exceeded recommendations. There is a need to support clinicians in the diagnosis of HF in primary care, with improved access to investigation and specialist assessment to support timely management.

  • heart disease
  • quality And Outcomes Of Care

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  • Contributors BH, DK and AB conceived and designed the 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. All authors commented on and helped to revise drafts of this paper. All authors have approved the final version. BH is the guarantor.

  • Funding This work was partly supported by Dr Foster®, a private healthcare information company, via a research grant to the Dr Foster Unit at Imperial College London. The Dr Foster Unit at Imperial College London is also partly funded by research grants from the National Institute for Health Research (NIHR) including the Imperial Patient Safety Translational Research Centre. Prof Cowie’s salary is supported by the NIHR Cardiovascular Biomedical Research Unit at the Royal Brompton Hospital, London. This research was also supported by the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care Northwest London (NIHR CLAHRC NWL).

  • Disclaimer The views expressed in this article are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

  • Competing interests BH and AM are both general practitioners, and MC a consultant cardiologist, working in the NHS.

  • Patient consent Not required.

  • Ethics approval We have approval from the Secretary of State and the Health Research Authority under Regulation 5 of the Health Service (Control of Patient Information) Regulations 2002 to hold confidential data and analyse them for research purposes (CAG ref 15/CAG/0005). We have approval to use them for research and measuring quality of delivery of healthcare, from the London - South East Ethics Committee (REC ref 15/LO/0824). The CPRD Group has obtained ethical approval from a National Research Ethics Service Committee (NRES) for all purely observational research using anonymised CPRD data. This study has been carried out as part of the work approved by their Independent Scientific Advisory Committee (ISAC) with protocol number 16_003RAR.

  • 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.

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