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Worldwide, cardiovascular
disease affects the lives of hundreds of millions,
Dedicated cardio nerds everywhere. Are working hard to
fight this global epidemic. These are their stories.
Hi, everyone. Dan M here. On behalf of
all of us at coordinators, we are thrilled
to bring you our decipher for the guideline
syringe for the 20 20 2AHA
guideline for the management of heart failure, get
ready for short and bite sized, high impact
critical did yet based questions designed to highlight
core concepts based on cutting edge evidence that
are relevant to your practice. The cases we
use are hypothetical and for educational purposes only.
This series was developed by car and created
in collaboration with the American
association and the Heart failure Society of America.
It was created by 30 trainees spanning college
students through advanced fellowship with mentorship doctor Anu
la, Doctor. Robert Men and Doctor. Nancy Sc,
we thank Doctor. Judy And doctor Elliot Amin
for their guidance. So join us as we
get to learn about the guidelines and beyond
from 16 leading faculty experts. With that said,
it's time to get nerdy.
The following question refers to section 5.1 of
the 2022
a
acc, H guidelines for the management of heart
failure.
The question is asked by ke School of
Medicine and Usc Medical student and cardio earth's
intern, First El,
answered first by recent advanced heart failure and
transplant fellowship graduate and our faculty at the
University of Chicago and c chair for the
Cardio critical care cardiology series, Doctor Mark Be,
and then by expert faculty, Doctor Vi Bo.
Doctor. Ba is the Marion Gordon Keen sc,
professor of Medicine,
director of the Winter center for heart failure
research and an advanced heart failure and transplant
cardiologist
at Baylor College of Medicine in Houston, Texas.
She the former president of H,
former senior associate editor for circulation, and the
current editor and chief of Jack Heart failure.
Doctor Bo was the Vice chair of the
writing committee for the 2002 heart failure guidelines.
Doctor Bo is an honor to have you
with us. A great pleasure for me to
be with you at the cardio nerds. It's
a fantastic platform for timely and insightful
conversations in cardiology and heart failure.
Thank you for inviting me.
Jason, thank you so much for the intro.
And Mark, my question for you today is
about a 63 year old patient with the
past medical history of hypertension. And type 2
diabetes
who presents for routine follow up.
Your reports feeling in general Good health and
enjoys 2 mile walks daily
Review of symptoms is negative for any symptoms.
Which of the following laboratory studies may be
beneficial for screening.
Option a is Nt prob b p,
option b, ck k mb.
Option c, troponin,
option d,
Crp
and option e, none of the above. And,
Mark, oh, yeah, I love your help figuring
out what the next step should be for
this patient. Thanks Harsh. That's a great question
and comes up frequently clinic.
Correct answers is a, nt prob p. The
patient's at risk for heart failure or stage
a, given the presence of risk factors of
hypertension and type 2 diabetes, but absence of
signs of symptoms of heart failure.
Patients at risk for heart failure screened with
B p or anti nt prob
followed by collaborative care, diagnostic
evaluation and treatment in those elevated levels can
reduce combined rates of L systolic dysfunction, diastolic
dysfunction and heart failure.
The stop H trial, which was the saint
vincent screening to prevent heart failure study, is
a large single center trial of patients at
risk for heart failure. That showed B based
screening reduce the composite endpoint of incident
asymptomatic L dysfunction with or without newly diagnosed
heart failure.
Therefore, for patients at risk of developing heart
failure,
peptide biomarker a based screening followed by team
based care, including a cardiovascular specialist optimizing guidelines
directed medical therapy can be useful to prevent
the development of l dysfunction, whether assist systolic
diastolic or and heart failure. Find Is that
class 2a a recommendation with the level evidence
b from a randomized control trial. There is
no indication for measuring troponin, Ck b or
Cr at this time. The main takeaway here
is in patients at risk for heart failure,
screening for pre heart failure using peptide testing
followed by team based care may be helpful
for preventing disease progression.
So about Actually in in my short time
now is faculty have seen us a few
times in clinic. The guidelines are pretty clear
in 1 to screen of peptides, but how
often do you repeat the testing after your
initial screen?
It's a great question. And the examine what
was done in this stop H f trial,
which, this recommendation was formulated
from, they screen on an annual basis.
The approach was very well structured, and a
randomized to the B screening versus own screening.
And if
Amongst the screen ones on an annual basis,
B levels exceeded that of 50.
Per liter is actually a relatively
low value.
If the level exceeded that of 50, they
down refer to this multi disciplinary chair coordination
that included a cardiovascular specialist, As to 1
wonders what did they exactly do because these
individuals were with hypertension diabetes, coronary artery disease,
but without
established heart failure. So what they did was,
they actually
image
and treated the risk factors very effectively.
And when they
enhanced this risk treatment strategies,
the endpoint was very striking in the sense
that both the future development of heart failure,
mace events, and future development of diastolic or
systolic
dysfunction was prevented. So a very important trial
and that gives a glimpse into what this
structure of the screening could be. So back
to your question, top H trial
screened on an annual basis.
Perhaps 1 approach could be
the risk.
If the risk is high, annual screening makes
sense. If the risk is low, like that
23 year old, 1 and probably reduce the
frequency of screening to several years apart. And
maybe only do it when there is a
change either in the profile and or in
the risk category. So the population based screening
levels
rely on cost effectiveness and the pre test
likelihood.
And the stop H trial actually was further
analyzed and the B based screening was found
to be cost effective, and thus it is
likely gonna be in rated in our practice,
especially for the patient, like, the 1 that
you just presented, who truly would benefit from
a screening and optimization of treatment strategies that
are targeted towards heart failure. And it should
be kept in mind that in the Stop
H trial,
there was a multi
disciplinary team. In the
recommendations that we formulated,
we recommend or patients at risk or development
of heart failure,
nat peptide
by a marker based screening followed by
team based care, including a cardiovascular
specialist,
optimizing the guideline directed therapy can be useful
to prevent
feature the development of L dysfunction,
as well as new ones onset heart failure.
The only challenge right now is The
recognition for screening is there among specialists.
It's not widely known by primary care providers,
and it's not widely adopted by the healthcare
systems
and not covered by the payers.
So the importance of this
recognition is critical
or our patients to be provided timely care
This is very similar to screening for cancer
because we now in heart failure as we
discussed earlier that there are specific
treatment strategies that prevents heart failure. And in
individuals who are at higher risk for heart
failure,
treatment with These specific agents such as a
2 inhibitors amongst patients with diabetes
can prevent forte by about 30 percent.
Thus screening is critical
to prevent future risk for development of heart
failure. And I think that's gonna be an
important concept
as we of as healthcare care clinicians
advocate for our patients, for appropriate coverage and
timely care. A fantastic Doctor. Ba I think
that's a key point about the recommendations and
updated guidelines being there and then that translating
into
education for clinicians specifically outside of advanced heart
failure and cardiology and then and the payers.
A follow question I had in terms of
screening, for
yearly screening and let's say a high risk
patient, who many of our patients happen to
have hypertension diabetes that may also be obese.
And we know that Bm tends to be
falsely low in patients with obesity? How would
you interpret B p screening in this type
of situation? 2 answers. In the selling of
mobile obesity, we do know that the peptide
levels will be low. And there are other
modalities by which 1 can examine the heart
and the filling pressures, including
echo c
and other imaging. In the context of a
morbid obese individuals who may even have symptoms
because most of our patients actually do have
symptoms of d, it would be prudent to
of contain imaging in those patients to look
at the left atrial size, the mitral inflow,
at the wall thickness, the structure of the
heart in terms of overall ejection fraction as
well as variables that may suggest diastolic is
dysfunction or even elevated filling pressure. So the
concept of screening,
I believe is gonna evolve as the field
has more evidence
supporting these strategies. There are currently large scale
echo
data, demonstrating very similar,
role for echo screening. As you... We are
all aware, we have now, a very practical
focus point of care ultrasound as well as
other
imaging modalities that are being widely available.
And I think this paradigm is gonna evolve
with even digital technologies that may look at
the cardiac structure in a non amazing manner
and the ability to detect cardiac structural.
May not need to solely rely on biomarkers
markers in essence, nat peptides are an indirect
way of demonstrating
increased filling pressures or myocardial stretch.
Maybe if we were to have affordable, widely
available,
practical
imaging, they could complement biomarker a screening or
in the setting of obesity as you alluded
to add specificity.
And sensitivity.
It's very helpful clarification, and look forward to
further screening patients and being able to combat
heart failure.
With the new guidelines.
Thank you. These were excellent cases, and thanks
for the discussion, and the opportunity to provide
the perspective we'll how the recommendations were formulated
in the guidelines with evidence from the clinical
trials. Thank you so much, Doctor. Ba and
marked for that really wonderful discussion.
Thank you. It was a true pleasure.