Elderly primary care hypertension patients–who to refer for echocardiography?

Heart failure (HF) is a complex clinical syndrome resulting from impaired diastolic and/or systolic function and clinically manifested by numerous, rather unspecific symptoms such as dyspnoea (at rest or exertion), orthopnoea, wheezing, chronic fatigue and lower extremity oedema. The prevalence of HF increases steeply with age, causing high mortality and morbidity , substantial loss in quality of life, and high health care costs [1]. For the diagnosis of HF, guidelines require, in addition to symptoms, objective evidence of cardiac dysfunction that is most commonly assessed by echocardiography. While many conditions may cause HF, the most common aetiologies are coronary artery disease (CAD) and hypertension. Early diagnosis and adequate treatment are necessary to improve symptoms and prognosis. General practitioners (GPs) and nurse practitioners (NPs) play a key role in identifying HF, but diagnosing HF in primary care remains challenging because symptoms are often unspecific, subtle or even absent [2]. Advanced diagnostics are often not easily available , but diagnostic uncertainty may lead to inappropriate treatment of wrongly diagnosed HF or delaying therapy when the diagnosis is missed. Echocardiography is the reference investigation for left ventricular dysfunction and plays an important role to diagnose both diastolic and systolic dysfunction of the left ventri-cle (class I, level C) [3]. There is an increase in the number of open access echocardiography services to primary care for early diagnosis and appropriate treatment of cardiac dysfunction and HF. However, due to limited resources, adequate screening by GPs or NPs remains imperative for cost-effective use of limited resources. The question, therefore, arises which patients should be investigated by echocardiography to provide best care. The equivocal recommendation by the most recent guidelines on the management of arterial hypertension by the ESC underscores the difficulty of this question [4]. In this issue of the Netherlands Heart Journal, Ringoir et al. report on the prevalence of symptoms related to HF in 591 elderly primary care patients with hypertension and the diagnostic value of these symptoms to predict cardiac dysfunction, defined as an abnormal echocardiogram [5]. The investigators included both systolic (LVEF < 55 %) and diastolic dysfunc-tion parameters (left atrial volume index > 29 ml/m 2 , E/a ratio < 1 and DT > 200 ms in presence of left ventricular hypertro-phy), as well as valvular abnormalities, wall motion abnormalities , and right ventricular hypertrophy (≥ 6 mm) in their definition of an abnormal echocardiogram, which was found in 30 …