Stability of chronic heart failure from the position of a doctor and a patient: in search of contact points

Abstract

Actuality. The results of the EPOCH study showed that in 16 years in the Russian Federation the number of patients with chronic heart failure (CHF) of I–IV FC increased significantly. The main objectives of the treatment of CHF are the stabilization of the patient's condition and the reduction of the risks of cardiovascular mortality, decompensation and repeated hospitalizations for heart failure. But a single concept of “stable” CHF does not exist either in Russian or in foreign recommendations. Objective. To assess how ofen the subjective assessment of a doctor regarding the stability of a patient with CHF coincides with the subjective opinion of the patient with CHF regarding the stability of his condition; and to identify those parametrs that have a leading influence on the assessment of the stability of the state from the point of view of the physician and the patient. Materials and methods. Data collection was carried out in the form of interviews among general practitioners and cardiologists in outpatient clinics (OC) of Nizhny Novgorod, which were randomly selected by the method of blind envelopes. In parallel, a survey was conducted of patients with CHF who applied for outpatient medical care about this syndrome to this OC, which the doctors were not informed about, because patient interviews were conducted after the end of outpatient admission in a separate room. Answers of doctors about a patient with CHF were compared with the answers of the corresponding patient; for this, a single code was assigned to both questionnaires. The study included 211 patients with CHF of any etiology older than 18 years. The study involved 25 doctors. The study was conducted from 11/01/17 to 11/30/17. Results: Analysis of the data suggests that the doctor is more likely to consider the patient more stable in cases when the patient notes a decrease in the severity of shortness of breath, weakness and does not detect edema, while the fact of therapy with loop diuretics (LD) or an increase in them did not affect assessment of stability from the point of view of the doctor. From the point of view of the patient, the absence of the first three signs also testifies to the stability of the condition, however, unlike doctors, patients more often (p <0.001) considered themselves unstable in those cases when they needed LD therapy or an increase in LD dose. A logit regression analysis and ROC analysis based on selected signs and symptoms of CHF confirmed that a model that combines questions about persistent weakness and edema is best suited to predict the patient’s subjective assessment of patient’s stability from a doctor’s point of view (61.8% of the results can be correctly predicted), and at the cutoff threshold of 0.5, it has the highest sensitivity of 64.9%. To predict the subjective assessment of stability in relation to the patient, the optimal model turned out to be the one that includes answers to the questions of “shortness of breath”, “weakness” and “intake of loop diuretics”, which allows to predict 66.7% of the results correctly at the cut‑off threshold 0, 5 has a better balance of sensitivity and specificity (54.9 and 78.6, respectively). Conclusion. Reducing the severity of dyspnea, weakness and lack of edema of the lower extremities are important signs of the stability of the condition, both in the opinion of the doctor and in the opinion of the patient. Unlike the doctor, the patient is more likely to be classified as unstable in those cases when he is forced to receive therapy with loop diuretics at the outpatient stage or to increase their dose. The model for assessing the stability of a patient with CHF from the point of view of a physician more often allows one to confirm the patient’s stable condition, while the model used by patients more often allows to identify patient instability and worsening of the course of CHF.