title: Are the heart failure guidelines being implemented in primary care?
abstract: BACKGROUND
  Heart failure (HF) is an important public health concern in Brazil due to its high prevalence. Our objective was to study the performance of primary care physicians of the public health system in the management of heart failure in the city of Niterói, Rio de Janeiro state, comparing their practice to that recommended by the Brazilian Society of Cardiology (BSC) guidelines.
  
  
  METHODS
  In a cross-sectional study, 167 patients aged over 18, with a primary diagnosis of heart failure (HF), were studied at the university hospital by questionnaire, physical exam, electrocardiogram (ECG), chest X-ray, and echocardiogram (echo) as the gold standard exam.
  
  
  RESULTS
  HF was not confirmed by echo criteria in 56 cases (33.5%). Sixty-nine patients (40.6%) had not previously undergone any diagnostic exam. Mean age was 61 years (+/- 13.3) and 57% were women. The main divergences from the guidelines were underuse of echo (11.4%), angiotensin-converting enzyme inhibitors (ACEIs) (64.1%) and beta-blockers (BBs) (26.0%), and the most often prescribed of the latter were those without benefits in morbidity and mortality --propranolol (15.6%) and atenolol (6.6%). The association of ACEIs and BBs was used in 25% of patients. Diuretics were the most prescribed (64.7%) and spironolactone was used in 9.0% of cases.
  
  
  CONCLUSIONS
  There is a significant divergence between primary practice and the BSC guidelines. In this setting, the limited availability of echo and of the recommended drugs, combined with a lack of information, restricts their use. A program to improve adherence to the guidelines and to an evidence-based approach, through continuous medical training, should be implemented to improve the quality of primary care.
authors.affiliation: Center for Autoimmune Diseases and Department of Medicine B, Sheba Medical Center, Tel- Hashomer, Sackler Faculty of Medicine, Tel Aviv University, Israel.
authors.forename: Samuel-Datum
authors.initials: SD
authors.lastname: Moscavitch
authors.forename: Juliana Lago
authors.initials: JL
authors.lastname: Garcia
authors.forename: Lorraine Furlane
authors.initials: LF
authors.lastname: Rosa
authors.forename: Paula Ramos
authors.initials: PR
authors.lastname: Pestana
authors.forename: Lívia Valente
authors.initials: LV
authors.lastname: Moraes
authors.forename: Carla Oliveira Monteiro
authors.initials: CO
authors.lastname: da Silva
authors.forename: Marco Aurélio Esposito
authors.initials: MA
authors.lastname: Moutinho
authors.forename: Flavio Augusto Colucci
authors.initials: FA
authors.lastname: Coelho
authors.forename: Maria Luiza Garcia
authors.initials: ML
authors.lastname: Rosa
authors.forename: Evandro Tinoco
authors.initials: ET
authors.lastname: Mesquita
mesh_terms: D003430:Cross-Sectional Studies; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D006333:Heart Failure / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011320:Primary Health Care