Notfall & Hausarztmedizin 2007; 33(1): 14-19
DOI: 10.1055/s-2007-973419
Notsituation

© Georg Thieme Verlag Stuttgart · New York

Früherkennung der Herzinsuffizienz beim älteren Menschen - Schlechte Prognose macht Screening empfehlenswert

Early diagnosis and treatment of heart failure in the elderly - The poor prognosis makes screening recommendableThomas Steger1 , Thomas Karg2 , Hagen Sandholzer3
  • 1Lehrbeauftragter der Abteilung Allgemeinmedizin, Universität Leipzig
  • 2Professur für Allgemeinmedizin, Gießen
  • 3Leiter der Abteilung Allgemeinmedizin, Universität Leipzig
Weitere Informationen

Publikationsverlauf

Publikationsdatum:
07. März 2007 (online)

Bei der Herzinsuffizienz handelt es sich um ein häufiges, klinisch bedeutsames und therapierbares Krankheitsbild in der Allgemeinpraxis. Zu den anerkannten Risikogruppen für Herzinsuffizienz gehören Patienten mit Hypertonie und koronarer Herzkrankheit, Klappenfehlern und anderen kardialen Vorerkrankungen. In der Hausarztpraxis kommt eine Herzinsuffizienz vor allem bei älteren Patienten vor, speziell bei über 75-Jährigen und Patienten mit Zustand nach Myokardinfarkt, Diabetes mellitus, koronarer Herzkrankheit und Hypertonie. Die Diagnose einer Herzinsuffizienz sollte frühzeitig gestellt werden, da bereits bei asymptomatischen Patienten mit eingeschränkter linksventrikulärer Funktion eine Therapie die Prognose bessert. Allein anhand der klassischen Anamnese und Befunde lässt sich die Diagnose nicht mit ausreichender Sicherheit stellen oder ausschließen. Daher wird empfohlen, Risikogruppen während der üblichen Vorsorgeuntersuchungen regelmäßig nach Atemnot oder abnormer Müdigkeit zu befragen und auf das EKG zu achten. Da ein normales 12-Kanal-EKG eine Herzinsuffizienz unwahrscheinlich macht, sind vor allem ältere Patienten mit pathologischem EKG Kandidaten für eine frühzeitige echokardiographische Untersuchung. Wegen der hohen Kosten des Labortests (BNP) und der nicht ausreichenden Evidenz muss hier die weitere Entwicklung bezüglich der Ergebnisse neuerer Studien und sozialrechtlicher Fragen abgewartet werden.

Heart failure is a common major clinical problem in general practice. Recognized risk groups for heart failure include patients with hypertension and coronary artery disease, heart valve disease and other cardiac conditions. In general practice, heart failure is seen in particular in the elderly patient, especially in over-75-year-olds and patients after a myocardial infarction, diabetes mellitus, coronary artery disease or hypertension. The diagnosis should be established as early as possible, since asymptomatic patients with reduced ventricular function respond to treatment with an improved prognosis. The diagnosis cannot be established or excluded with sufficient certainty on the basis of the classical history and findings alone. It is therefore recommended that during the usual screening examination risk groups should regularly be questioned about breathlessness or unusual fatigue, and attention be given to the ECGH. Since a normal 12-lead ECG makes heart failure unlikely, in particular elderly patients with a pathological ECG are candidates for an early echocardiographic examination. The expense of laboratory tests (BNP) and lack of evidence make it necessary to await the results of more recent studies and the answers to sociolegal questions.

Literatur

  • 1 ACC/AHA 2002: American College of Cardiology/American Heart Association .ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult).  www.americanheart.org/downloadable/heart/1013201138293HFGuidelineFinal.pdf
  • 2 AKDAE 2001: Arzneimittelkommission der deutschen Ärzteschaft .Chronische Herzinsuffizienz. Empfehlungen zur Therapie der chronischen Herzinsuffizienz.  www.akdae.de/35/10Hefte/88_Herzinsuffizenz_2001_2Auflage.pdf
  • 3 Badgett RG, Lucey CR, Mulrow CD. Can the clinical examination diagnose left-sided heart failure in adults?.  JAMA. 1997;  277 1712-1719
  • 4 Brophy JM, Joseph L, Rouleau JL. Beta-blockers in congestive heart failure. A Bayesian meta-analysis.  Ann Intern Med. 2001;  134 550-560
  • 5 Cardarelli R, Lumicao TG. B-type Natriuretic Peptide: A Review of Its Diagnostic, Prognostic, and Therapeutic Monitoring Value in Heart Failure for Primary Care Physicians.  J Am Board Fam Pract. 2003;  16 327-333
  • 6 CCS 2002/3: Canadian Cardiovascular Society .The 2002/3 Canadian cardiovascular society consensus guideline Update for the Diagnosis and Management of Heart Failure.  www.ccs.ca/download/CCSHFConsUpdateDraft0103EMail.pdf
  • 7 Ceia F, Fonseca C, Mota T. et al. . Prevalence of chronic heart failure in Southwestern Europe: the EPICA study.  Eur J Heart Fail. 2002;  4 531-539
  • 8 Clarke KW, Gray D, Hampton JR. Evidence of inadequate investigation and treatment of patients with heart failure.  Br Heart J. 1994;  71 584-587
  • 9 Cleland JG, Cohen-Solal A, Aguilar JC. et al. . IMPROVEMENT of Heart Failure Programme Committees and Investigators* and the Study Group on Diagnosis of the Working Group on Heart Failure of The European Society of Cardiology Management of heart failure in primary care (the IMPROVEMENT of Heart Failure Programme): an international survey.  Lancet. 2002;  360 1631-39
  • 10 Cohn JN, Tognoni G. Valsartan Heart failure Trial investigators. . A randomised trial of the angiotensin-receptor blocker valsartan in chronic heart failure.  N Engl J Med. 2001;  345 1667-1675
  • 11 Cowie MR, Struthers AD, Wood DA. et al. . Value of natriuretic peptides in assessment of patients with possible new heart failure in primary care.  Lancet. 1997;  350 1349-1353
  • 12 Davie AP, Francis CM, Caruana L. et al. . Assessing diagnosis in heart failure: which features are any use?.  QJM. 1997;  90 335-339
  • 13 Davie AP, Francis CM, Love MP. et al. . Value of the electrocardiogram in identifying heart failure due to left ventricular systolic dysfunction.  BMJ. 1996;  312 222
  • 14 Dracup K, Baker DW, Dunbar SB. et al. . Management of heart failure. II. Counseling, education, and lifestyle modifications.  JAMA. 1994;  272 1442-1446
  • 15 ESC 2001 . Task Force for the Diagnosis and Treatment of Chronic Heart Failure, European Society of Cardiology: Remme WJ & Swedberg K. Guidelines for the diagnosis and treatment of chronic heart failure.  Eur Heart J - www.escardio.org/knowledge/guidelines/Chronic_Heart_Failure.htm . 2001;  22 1527-1560
  • 16 Fischer M, Baessler A, Holmer SR. et al. . Epidemiology of left ventricular systolic dysfunction in the general population of Germany: results of an echocardiographic study of a large population-based sample.  Z Kardiol. 2003;  92 294-302
  • 17 Garg R, Yusuf S. Overview of randomized trials of angiotensin-converting enzyme inhibitors on mortality and morbidity in patients with heart failure. Collaborative Group on ACE Inhibitor Trials.  JAMA. 1995;  273 1450-1456
  • 18 HFSA 1999: Heart Failure Society of America. .HFSA guidelines for management of patients with heart failure caused by left ventricular systolic dysfunction: Pharmacological approaches.  www.hfsa.org/hf_guidelines.asp
  • 19 Hobbs R. Can heart failure be diagnosed in primary care.  Editoral BMJ. 2000;  321 188-189
  • 20 Hobbs FD, Jones MI, Allan TF. et al. . European survey of primary care physician perceptions on heart failure diagnosis and management (Euro-HF).  Eur Heart J. 2000;  21 1877-1887
  • 21 James PA, Cowan TM, Graham RP. et al. . Heart failure in primary care: measuring the quality of care.  J Fam Pract. 1999;  48 790-798
  • 22 Jong P, Demers C, McKelvie RS, Liu PP. Angiotensin receptor blockers in heart failure: meta-analysis of randomized controlled trials.  J Am Coll Cardiol. 2002;  39 463-470
  • 23 Lloyd-Williams F, Mair FS, Leitner M. Exercise training and heart failure: a systematic review of current evidence.  Br J Gen Pract. 2002;  52 47-55
  • 24 Mair FS, Crowley TS, Bundred PE. Prevalence, aetiology and management of heart failure in general practice.  Br J Gen Pract. 1996;  46 77-79
  • 25 Maisel AS, Krishnaswamy P, Nowak RM. et al. . Rapid measurement of B-type natriuretic peptide in the emergency diagnosis of heart failure.  N Engl J Med. 2002;  347 161-167
  • 26 Marantz PR, Tobin JH, Wasseslheit-Smaller S. et al. . The relationship between left ventricular systolic function and congestive cardiac failure diagnosed by clinical criteria.  Circulation. 1988;  77 607-612
  • 27 McKelvie RS, Ysuf S, Pericak D. et al. . Comparison of candesartan, enalapril, and their combination in congestive heart failure. Randomised Evaluation of strategies for left ventrikular Dysfunction (resolvd) Pilot study.  Circulation. 1999;  100 1056-1064
  • 28 McMurray JJ, Petrie MC, Murdoch DR, Davie AP. Clinical epidemiology of heart failure: public and private health burden.  Eur Heart. 1998;  19 9-16
  • 29 McMurray JV, McDonagh TA, Davie AP. et al. . Should we screen for asymptomatic left ventricular dysfunction to prevent heart failure?.  Eur Heart J. 1998;  19 842-846
  • 30 Misuraca G, Serafini O, Caporale R. et al. . Diagnosis of heart failure in general medicine: role of cerebral natriuretic peptide. Results of a pilot study of a population sample from Calabria.  Ital Heart J. 2002;  3 928-932
  • 31 Morgan S, Smith H, Simpson I. et al. . Prevalence and clinical characteristics of left ventricular dysfunction among elderly patients in general practice setting: cross sectional survey.  BMJ. 1999;  318 368-372
  • 32 Murdoch DR, Love MP, Robb SD. et al. . Importance of heart failure as a cause of death. Changing contribution to overall mortality and coronary heart disease mortality in Scotland 1979-1992.  Eur Heart. 1998;  19 1829-1835
  • 33 NHF/Austr and CSANZ 2002: National Heart Foundation of Australia and Cardiac Society of Australia & New Zealand. .Guidelines on the Contemporary Management of the Patient with Chronic Heart Failure in Australia.  www.csanz.edu.au/guidelines/practice/Chronic_Heart_Failure.pdf
  • 34 NHF/NZ 2001: National Heart Foundation of New Zealand. .A guideline for the management of chronic heart failure.  www.heartfoundation.org.nz/files/Cardiac_Care/heart_failure_guidelines.pdf
  • 35 NICE 2003: The National Collaborating Centre for Chronic Conditions .Chronic Heart Failure. National clinical guideline for diagnosis and management in primary and secondary care. NICE Guide-line No. 5. www.nice.org.uk
  • 36 Nielsen OW, Hansen JF, Hilden J. et al. . Risk assessment of left ventrikular systolic dysfunktion in primary care: cross sectionel study eveluating a range of diagnostic tests.  BMJ. 2000;  320 220-224
  • 37 Nilsson G, Strender LE. Management of heart failure in primary health care. A retrospective study on electronic patient records in a registered population.  Scand J Prim Health Care. 2002;  20 161-165
  • 38 Pitt B, Zannad F, Remme WJ. et al. . The effect of spironolactone on morbidity and mortality in patients with severe heart failure. Randomized Aldactone Evaluation Study Investigators.  N Engl J Med. 1999;  341 709-717
  • 39 Pitt B, Poole-Wilson RA, Segal R. the elite II Investigators . Effect of losartan compared with captopril on mortality in patients with symptomatic heart failure: randomised trial - the losartan heart failure survival study Elite II.  Lancet. 2000;  355 1582-1587
  • 40 Remes J, Miettinen H, Reunanen A, Pyorala K. Validity of clinical diagnosis of heart failure in primary health care.  Eur Heart J. 1991;  12 315-321
  • 41 Samuel R. Heart failure. BMJ Publishing Group. Clinical Evidence: The international source of the best available evidence for effective health care. 10. Issue Dezember 2003.  London: BMJ Publishing Group. 2003;  10 118-140
  • 42 Sandholzer H. Sollten Hausärzte ihre Patienten auf Herzinsuffizienz screenen - und wenn ja, welche?.  Herz und Gefäße für die Hausarztpraxis. 2004;  1 7-11
  • 43 Sharma D, Buyse M, Pitt B, Rucinska EJ. Meta-analysis of observed mortality data from all-controlled, double-blind, multiple-dose studies of losartan in heart failure. Losartan Heart Failure Mortality Meta-analysis Study Group.  Am J Cardiol. 2000;  85 187-192
  • 44 The Antiarrhythmics versus Implantable Defibrillators (AVID) Investigators: A comparison of antiarrhythmic-drug therapy with implantable defibrillators in patients resuscitated from near-fatal ventricular arrhythmias.  N Engl J Med. 1997;  337 1576-1583
  • 45 The Digitalis Investigation Group . The effect of digoxin on mortality and morbidity in patients with heart failure.  N Engl J Med. 1997;  336 525-533
  • 46 The SOLVD Investigators . Effect of Enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure.  N Engl J Med. 1991;  325 293-302
  • 47 Chavey II WE, Blaum CS, Bleske BE, Harrison R Van, Kesterson S, Nicklas JM. UM 2001: University of Michigan. .Guideline for the management of heart failure caused by systolic dysfunction: Part I. Guideline developement, etiology and diagnosis. Part II. Treatment. American Family Physician www.aafp.org/afp/20010915/1045.pdf, www.aafp.org/afp/20010901/769.pdf 2001: 769-1054
  • 48 UWH 2002: Wissensnetzwerk „evidence.de” der Universität Witten/Herdecke .Herzinsuffizienz: Evidenzbasierte Leitlinie zu Diagnose und Therapie.  www.evidence.de/Leitlinien/leitlinien-intern/Herzinsuffizienz_Start/herzinsuffizienz_start.html
  • 49 Vasan RS, Benjamin EJ, Larson MG. et al. . Plasma natriuretic peptides for community screening foleft ventricular hypertrophy and systolic dysfunction: the Framingham heart study.  JAMA. 2002;  288 1252-1259
  • 50 Yusuf S, Pfeffer MA, Swedberg K. et al. . Effects of candesartan in patients with chronic heart failure and preserved left-ventricular ejection fraction: the CHARM-Preserved Trial.  Lancet. 2003;  362 777-781
  • 51 Wang TJ, Levy D, Benjamin EJ, Vasan RS. The epidemiology of „asymptomatic” left ventricular systolic dysfunction: implications for screening.  Ann Intern Med. 2003;  138 907-916
  • 52 Wheeldon NM, MacDonald TM, Flucker CJ. et al. . Echocardiography in chronic heart failure in the community.  Q J Med. 1993;  86 17-23
  • 53 Beschlussbegründung des Gemeinsamen Bundesausschusses zur Empfehlung geeigneter chronischer Krankheiten für strukturierte Behandlungsprogramme gemäß § 137 f Absatz 1 Satz 1 SGB V vom 16.05.2006.  www.g-ba.de/cms/upload/pdf/abs4/beschluesse/2006-05-16-dmp-Module_Gruende.pdf
  • 54 Fuat A, Murphy JJ, Hungin AP. et al. . The diagnostic accuracy and utility of a B-type natriuretic peptide test in a community population of patients with suspected heart failure.  Br J Gen Pract. 2006;  56 327-333
  • 55 Davenport C, Cheng EY, Kwok YT. et al. . Assessing the diagnostic test accuracy of natriuretic peptides and ECG in the diagnosis of left ventricular systolic dysfunction: a systematic review and meta-nalysis.  Br J Gen Pract. 2006;  56 48-56
  • 56 Hobbs FD. Management of heart failure: evidence versus practice. Does current prescribing provide optimal treatment for heart failure patients?.  Br J Gen Pract. 2000;  50 735-742
  • 57 Costello-Boerrigter LC, Boerrigter G, Redfield MM. et al. . Amino-terminal pro-B-type natriuretic peptide and B-type natriuretic peptide in the general community: determinants and detection of left ventricular dysfunction.  J Am Coll Cardiol. 2006;  47 345-353
  • 58 DEGAM Leitlinie Herzinsuffizienz.  www.degam.de/leitlinien/9_herzinsuffizienzs.html
  • 59 Adams. et al. . HFSA 2006 Comprehensive Heart Failure Practice Guideline.  J Card Fail. www.heartfailureguideline.org/index.cfm?id=37 . 2006;  12 e1-e119

Korrespondenz

Dr. med. Thomas Steger

Selbstständige Abteilung für Allgemeinmedizin, Universität Leipzig

Philipp-Rosenthal-Straße 55

04103 Leipzig

    >