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The American College of Cardiology, American Heart Association, and Heart Failure Society have revised 2013 heart failure (HF) guidelines in light of new evidence about the role of natriuretic peptides (NP) and other biomarkers in signaling damage to the heart.
The new guidelines support a combination of practices to assess which patients are on the path toward symptomatic HF. This includes a screening algorithm based on pre-existing and existing cardiovascular disease; early imaging; assessment by cardiovascular specialists; and assessment of the biomarker profile, Clyde W. Yancy, MD, MSc, MACC, FAHA, FHFSA, chair of the writing group for the document, told CLN Stat.
B-type NP (BNP), N-terminal proBNP (NT-proBNP), and mid-region-pro-atrial NP tests have recently gained credence as early diagnosis tools for HF.
“Even as influential guidelines in the U.S. and at least six other countries or regions have endorsed the NPs for these purposes, research continues into how they might be used to guide HF care. Vibrant NP-related research also has peeled back many layers of complexity about NP biochemistry as well as nuances in measuring these analytes,” Clinical Laboratory News reported in January.
An increasingly compelling body of work suggests that NP assessment should go beyond establishing or refuting the diagnosis of heart failure. Predischarge biomarker thresholds, particularly those for BNP, are highly predictive of future events. As an example, they can be useful in determining a postdischarge prognosis for a patient hospitalized with HF, Yancy said.
“With the entire [medical] community having such a laser focus on interventions that can reduce readmissions, we thought it was appropriate to point out the data” in the revised guidelines, he said.
The guidelines reflect new information from two important studies: the STOP-HF and PONTIAC trials, each of which incorporated NP as part of an interventional strategy to reduce or prevent cardiac events. The STOP trial, for example, randomized patients into a control group and an intervention group that underwent BNP testing. Those with BNP readings >50 pg/mL received early imaging and collaborative care from specialists. Incidence of heart failure and rates of emergency hospitalizations were about 50% lower for the intervention group, compared with the control group.
The authors specifically recommended BNP or NT-proBNP tests to predict the outcome or assess the severity of disease in chronic HF patients. For patients hospitalized with HF, the recommendation is to measure NP levels at predischarge, to give that patient a sense of his or her risk burden for HF, with an opportunity to pursue transitional care, early follow-up or disease management, said Yancy.
The hope is that practitioners may leverage the new data in the guidelines to identify patients at highest risk of readmissions for this condition, he said.
The authors also decided to remove statements on NP-guided therapy due to insufficient evidence that titrating evidence-based therapy led to improved outcomes. Yancy said the guideline authors may revisit this recommendation should new, more definitive data, pro or con, emerge.
For those patients with chronic HF additive risk stratification, clinicians should try other available tests, including those that measure biomarkers for myocardial injury or fibrosis.
The authors recommended screening patients at risk of developing HF. To prevent new onset HF or left ventricular dysfunction, they suggested a team-based care approach in which a cardiovascular specialist crafts a guideline-directed treatment plan. To support a diagnosis of HF or exclude it, the authors recommend testing inpatients who present with dyspnea.
To reduce hospitalizations among HF patients with preserved ejection fraction, the guideline authors recommended aldosterone antagonists under certain circumstances. This therapy would apply to patients with an elevated BNP or recent history of hospital admission for HF, an ejection fraction ≥45%, an estimated glomerular filtration rate >30 and creatinine <2.5 mg/dL, or a potassium level of <5.0 mEq/L.
They also recommended nitrates or phosphodiesterase-5 inhibitors as a routine therapy to improve quality of life or outcomes in patients with this condition.
Among their revisions to comorbidities guidelines, the authors suggested that patients with hypertension and an increased risk for HF aim for a blood pressure reading <130/80 mmHg. Patients with New York Heart Association class II–IV HF (ranging from mild symptoms to severe limitations) and suspected sleep disordered breathing or excessive daytime sleepiness should undergo a formal sleep assessment.
The authors also recommended specific therapies for patients experiencing sleep apnea symptoms in conjunction with heart problems.