{"id":37357,"date":"2013-07-18T06:00:16","date_gmt":"2013-07-18T10:00:16","guid":{"rendered":"http:\/\/blogs.nejm.org\/cardioexchange\/?post_type=voices&p=37357"},"modified":"2013-07-18T14:53:13","modified_gmt":"2013-07-18T18:53:13","slug":"bnp-based-screening-collaborative-care-to-prevent-heart-failure","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/cardioexchange\/2013\/07\/18\/bnp-based-screening-collaborative-care-to-prevent-heart-failure\/","title":{"rendered":"BNP-Based Screening + Collaborative Care to Prevent Heart Failure?"},"content":{"rendered":"

CardioExchange\u2019s John Ryan<\/b> interviews Kenneth McDonald<\/b> about the STOP-HF randomized trial, <\/i>published in JAMA<\/i><\/a>, of BNP-based screening versus usual primary care for preventing new-onset heart failure.<\/i><\/p>\n

THE STUDY<\/b><\/p>\n

Researchers randomized 1374 patients older than age 40 with at least one cardiovascular risk factor to receive usual primary care (control) or screening that involved brain-type natriuretic peptide (BNP) testing and, for patients with BNP levels \u226550 pg\/mL, echocardiography and collaborative care by the patient\u2019s PCP and a specialist cardiovascular center. The intervention group underwent significantly more cardiovascular investigations and received significantly more renin-angiotensin-aldosterone system (RAAS)\u2013based therapy.<\/p>\n

During a mean follow-up of 4.2 years, incidence of the primary endpoint \u2014 prevalence of asymptomatic LV systolic dysfunction with or without newly diagnosed heart failure \u2014 was significantly lower in the intervention group than the control group (5.3% vs. 8.7%), as was the incidence of asymptomatic LV systolic dysfunction alone (4.3% vs. 6.6%). New-onset heart failure was less common in the intervention group than in the control group (1.0% vs. 2.1%), but not significantly so.<\/p>\n

THE INTERVIEW<\/b><\/p>\n

Ryan: What mechanism do you think explains the difference in outcomes, especially given the small difference in RAAS-modifying therapy?<\/i><\/b><\/b><\/p>\n

McDonald:<\/i><\/b> <\/i>Great question. It was probably multifactorial. RAAS-modifying therapy likely made a contribution, but the data also showed strongly that improved adherence, likely encouraged by BNP-based CV coaching, played a role in better LDL management. That was despite any recorded difference in therapy between the groups and, similarly, a strong trend toward a lower rate of heart failure (HF) in the intervention arm without any change in HF-modifying therapies.<\/p>\n

Ryan: In the conclusion of the abstract, you report the combined endpoint instead of the primary endpoint. Could this give the false impression that there was a significant benefit in HF admissions?<\/i><\/b><\/b><\/p>\n

McDonald:<\/i><\/b> <\/i>I don\u2019t think so. The method of reporting the endpoint in the abstract was restricted by space. We wanted to remain faithful to the combined endpoint. It was an editorial decision, as I recall, to insert the data on asymptomatic LV systolic dysfunction as a stand-alone comment.<\/p>\n

Ryan: What needs to be done before we consider adopting BNP-based screening, given the small size of the trial and the use of a surrogate endpoint as the primary outcome?<\/i><\/b><\/b><\/p>\n

McDonald:<\/i><\/b> <\/i>Again, an important issue. We would like to see this interesting result confirmed by a large international trial.<\/p>\n

Ryan: If the benefit is driven by changes in diastolic dysfunction, what does that mean? How does that relate to outcomes?<\/i><\/b><\/b><\/p>\n

McDonald: <\/i><\/b>We did see a signal when confining the analysis to new-onset HF and asymptomatic LV systolic dysfunction, but nonetheless the endpoint was dominated by asymptomatic LV diastolic dysfunction. However, the asymptomatic left ventricular diastolic dysfunction at the level that we defined is a secure independent predictor of outcome for heart failure and other CV events, most notably atrial fibrillation. I agree that we don\u2019t yet know whether an intervention focused on asymptomatic LV diastolic dysfunction is effective. All that we can advocate for now is heightened attention to risk factors.<\/p>\n

 <\/p>\n

JOIN THE DISCUSSION<\/strong><\/p>\n

Do you think that BNP-based screening to prevent heart failure has promise? How does the present study affect your thinking?<\/b><\/p>\n","protected":false},"excerpt":{"rendered":"

Kenneth McDonald discusses findings from the STOP-HF randomized trial of BNP-based screening versus usual primary care for preventing new-onset heart failure.<\/p>\n","protected":false},"author":760,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[14],"tags":[854,287,452,1875],"class_list":["post-37357","post","type-post","status-publish","format-standard","hentry","category-heart-failure","tag-bnp","tag-heart-failure-2","tag-primary-care","tag-stop-hf"],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/37357","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/users\/760"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/comments?post=37357"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/37357\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/media?parent=37357"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/categories?post=37357"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/tags?post=37357"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}