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A Heart-Failure Prevention Strategy Put to the Test

Summary and Comment |
July 16, 2013

A Heart-Failure Prevention Strategy Put to the Test

  1. Frederick A. Masoudi, MD, MSPH, FACC, FAHA

An intervention based on biomarker screening yields improved rates of left ventricular dysfunction but uncertain clinical benefit.

  1. Frederick A. Masoudi, MD, MSPH, FACC, FAHA

The prevalence of heart failure (HF) is rising, despite progress in understanding and treating risk factors. In a nonblinded trial, 1374 adults (average age, 65; 45% men) with ≥1 risk factor for HF (≥3, 27%) underwent annual B-type natriuretic peptide (BNP) screening and were randomized to either BNP-guided intervention or usual care, in which BNP results were unavailable to providers. Intervention-group participants with elevated BNP levels (≥50 pg/mL) were referred for echocardiography and collaborative specialist–primary care. The primary endpoint was the composite of new-onset HF and left ventricular (LV) systolic dysfunction, with or without symptoms; because of slower-than-anticipated enrollment, LV diastolic dysfunction was added to the composite endpoint after trial inception.

During mean follow-up of 4.2 years, the revised primary endpoint occurred significantly less frequently in the intervention group than in the usual-care group (5.3% vs. 8.7%; odds ratio, 0.55). The rate of asymptomatic LV dysfunction was also lower in the intervention group (4.3% vs. 6.6%; OR, 0.57; P=0.01). The risk for symptomatic HF did not differ significantly between the two groups (1.0% vs. 2.1%; OR, 0.48; P=0.12), but the risk for emergency cardiovascular hospitalization was significantly lower in the intervention group (22.3 vs. 40.4 per 1000 patient-years). Of note, renin-angiotensin-aldosterone–inhibitor use was more common in the intervention group than in the usual-care group (56.5% vs. 49.6%).

Comment

This study is important as a relatively rigorous attempt to assess a preventive strategy for heart failure, but the results should not change practice. The lack of blinding could explain some of the outcome differences; the importance of asymptomatic left ventricular dysfunction — especially echocardiographic diastolic abnormalities — is of questionable importance to patients; and the feasibility of implementing the intervention in large populations remains unclear. Nonetheless, these findings should initiate a robust discussion about HF prevention, including the value of biomarkers for this purpose.

  • Disclosures for Frederick A. Masoudi, MD, MSPH, FACC, FAHA at time of publication Royalties Darling, Milligan, Smith & Lesch Grant / research support Agency for Healthcare Research and Quality; American College of Cardiology; Patient-Centered Outcomes Research Institute Editorial boards Circulation: Cardiovascular Quality and Outcomes Leadership positions in professional societies American College of Cardiology (Senior Medical Officer, National Cardiovascular Data Registries); American Heart Association (Vice Chair, Council on Quality of Care and Outcomes Research)

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Reader Comments (1)

Robert Hope Physician, australia

BNP range too wide to be highly specific.A2 inhibition required in predisposed medical conditions.6minute walk test plus symptoms eg..orthopnoea, ,are all useful standard features to emphasise

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