Delay in referral of high risk patients with hypertension and heart failure to specialized clinics in Canada, 1999 to 2008

Abstract:

Heart failure (HF) is commonly recognized as a complication of hypertension. Specialized outpatient HF clinics of the Canadian Heart Failure Network (CHFN) maintain a longitudinal database of patient characteristics, comorbidities and blood pressure (BP). At the time of referral, most patients have a low left ventricular ejection fraction (LVEF) with a systolic BP <140 mmHg. However, 2,529 patients (19% of the total cohort) were referred with a systolic BP >140 mmHg.
In this study cohort, at first data entry, 37% were female, mean age was 70.8+/-12.8(sd) yrs, LVEF was 37.3+/-15.2% and average duration of HF was 2.4+/-4.3 yrs. There was a documented history of hypertension in 60%, diabetes in 32% and obesity in 11%. The commonest limiting symptom was shortness of breath in 56%. Data were also analyzed in three groups by systolic BP >140-149, >150-159 and >160 mmHg at first HF database entry. Mean results: BP, 142/78 to 152/80 to 170/85mmHg (p<0.01); Age, 70 to 71 to 72yrs (p<0.05); Female, 36 to 36 to 41yrs (p<0.05); LVEF, 36 to 37 to 40% (p<0.01); HF duration, 2.7 to 2.3 to 2.1yrs (p<0.05); History of hypertension, 53 to 64 to 68% (p<0.05).
In these referred patients with systolic BP >140 mmHg, 29.7% had a clinic systolic BP >160 mmHg with a mean systolic of 170 mmHg and a mean diastolic BP of 85 mmHg. These patients were slightly older, were more likely to be female with a history of hypertension (though with a shorter duration) and had more preserved LV systolic function. As the documented duration of HF was over two years, these data suggest that referral to specialized multidisciplinary HF clinics is delayed. Identifying reasons for the delay and strategies for earlier referral may result in improved outcomes in this high risk population with both hypertension and heart failure.