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  • Ernie Mundell and Robert Preidt
  • Posted July 28, 2021

Primary Care Doctors Often Miss Heart Failure in Women, Black Patients

White men are more likely to a receive correct and timely diagnosis of heart failure in their primary care doctor's office compared to other types of patients, new research shows.

The serious and common heart ailment is too often missed in women, Blacks and poorer people when they see their health care provider for a regular appointment, the Stanford University researchers said.

Those groups are more likely to only have the condition spotted once they are rushed to emergency care.

All of this could have dire consequences for patients.

"Patients diagnosed with heart failure in the emergency room or during inpatient hospitalization often have more advanced heart failure and complications with worse prognoses than individuals diagnosed with heart failure in a primary care setting," explained study lead author Dr. Alexander Sandhu. He's an instructor of medicine in advanced heart failure in the division of cardiovascular medicine and the Stanford Cardiovascular Institute.

One expert called the findings a "wake-up call to primary care physicians and cardiologists."

Any type of patient "presenting with complaints of shortness of breath, leg swelling, cough and chest pain should have a comprehensive evaluation for cardiac disease and heart muscle dysfunction," said Dr. Guy Mintz. He directs cardiovascular health and lipidology at Northwell Health's Sandra Atlas Bass Heart Hospital, in Manhasset, N.Y.

"The earlier the answer, and the earlier the treatment regimen begins, the better the prognosis," Mintz said.

In their study, the Stanford team analyzed commercial insurance and Medicare Advantage health care claims data on nearly 1 million U.S. adults 18 or older diagnosed with heart failure between 2003 and 2019.

Of those patients, more than a third (38%) were diagnosed in an acute care setting, such as an emergency room or during a hospitalization.

Of the patients diagnosed in such settings, 46% had already displayed potential heart failure symptoms during primary care clinic visits over the previous six months, including swelling of tissues (15%), cough (12%), shortness of breath (11%), and chest pain (11%).

A diagnosis that came very late -- when the patient was experiencing a health emergency -- was more likely to be the case for women than for men, and for Black versus whites, the study found.

A patient's income seemed to matter, too: Patients with a net worth under $25,000 were 39% more likely to be diagnosed with heart failure in an ER or hospital than those with a net worth of over $500,000, according to the study published July 27 in the journal Circulation: Heart Failure.

The problem is only getting worse: Heart failure diagnoses made in acute care settings rose by 3.2% each year during the 16-year study period, the study authors said.

"Earlier recognition and treatment may prevent some of the serious complications and costs of heart failure," Sandhu said in a journal news release. "It is important to note that we only analyzed patients with health insurance, raising concerns that inequities may be even larger among people who are uninsured, marginally insured or those who have less access to care."

Dr. Michael Goyfman directs clinical cardiology at Long Island Jewish Forest Hills in New York City. He wasn't involved in the new study, but said its methodology brings up some uncertainties in interpreting the results.

For example, higher-income patients might live healthier lifestyles, impacting the timing of their diagnoses, Goyfman said. He said that many heart failure diagnoses might also have been incorrect, with other conditions -- asthma, emphysema or general poor health, for example -- possibly to blame for symptoms.

Still, "this study does bring attention to an important topic and highlights the possible need for interventions such as improved education to care providers for recognizing symptoms of heart failure and referring to cardiologists as appropriate," Goyfman said.

For his part, Mintz said "it is a medical embarrassment that 38% of these patients were diagnosed in an acute care setting and almost half had symptoms over the previous six months. Physicians should spend the time with patients needed to complete an accurate assessment."

More information

The U.S. National Heart, Lung, and Blood Institute has more on heart failure.

SOURCES: Guy Mintz, MD, director, cardiovascular health & lipidology, Northwell Health's Sandra Atlas Bass Heart Hospital, Manhasset, N.Y.; Michael Goyfman, MD, director, clinical cardiology, Long Island Jewish Forest Hills, New York City; Circulation: Heart Failure, news release, July 27, 2021

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