Primary care screening and prevention of heart failure coordinated by cardiologist in rural areas

Abstract

Abstract Purpose Current guidelines do not support community-wide screening for undetected asymptomatic left ventricular systolic dysfunction (LVSD), reduced (HFrEF), mid-range (HFmrEF) or preserved (HFpEF) heart failure (HF), either with natriuretic peptides (NTproBNP) or open access echocardiography (echo). Universal access to NTproBNP testing (with reimbursement in primary care) before referral for tissue doppler and speckle-tracking echo may be needed to facilitate HF diagnosis at earlier, more treatable stage. Methods 4376 consecutive patients (pts) were referred from January 2015 by general practitioners (GP) to echolab with suspected HF symptoms (unexplained breathlessness or ankle swelling). After confirmation elevated NTproBNP (>400 pg/mL) and MESA (Multi-Ethnic Study of Atherosclerosis) 5-year HF risk score ≥10 points and after exclusion significant valvular disease and abnormal electrocardiogram or chest x-ray in subgroup of randomly selected 829 asymptomatic elderly (≥65 years) pts (age 71±4 years, 48% women) with continued usual care by GP was compared with randomly selected 833 asymptomatic elderly pts from 5 GP practices in rural areas with prospective follow-up by regional cardiologist. Results At referral in both groups were similar baseline characteristics, 14% pts were treated with ACE-inhibitor (ACEi), 5% beta-blockers (BB) and 39% loop-diuretics. After cardiologist consultation loop-diuretics withdrawn in 90% pts, ACEi and BB use increased significantly to 98% and 82% in both groups (all p<0.001). Global LVSD (EF≤50%) was detected in 5% at baseline and 23% pts after 5 years in GP group, respectively 5.4% at baseline and 7% after 5 years in cardiologist group (p<0.001). Systolic dysfunction (S'≤6.0 cm/s) occurred in 14% at baseline and 38% pts after 5 years in GP group, respectively 15% at baseline and 21% after 5 years in cardiologist group (all p<0.001). Reduced global longitudinal (GLS<16%) observed in 20% at baseline and 51% pts after 5 years in GP group, respectively 21% at baseline and 29% after 5 years in cardiologist group (all p<0.001). At baseline we found 0.5% pts with new-onset HF in both groups (only HFmrEF). After mean follow-up of 54±4 months in cardiologist group developed new HF in 3% pts (1% HFmrEF, 2% HFpEF) compared with 19% pts (3% HFrEF, 7% HFmrEF, 9% HFpEF) in GP group (p<0.001). Significant (p<0.001) predictors of incident HFmrEF were systolic dysfunction (S'≤6.0 cm/s), hazard ratio (HR) 2.2, 95% CI 1.82–2.9) and reduced GLS (HR 3.5, 95% CI 3.1–3.9), all p<0.01. The strongest (p<0.001) predictors of incident HFpEF were new-onset atrial fibrillation (HR 1.9, 95% CI 0.9–3.9) and echo-detected left ventricular hypertrophy (septal and posterior wall thickness ≥13 mm, HR 1.52, 95% CI 1.22–1.89), all p<0.01. Conclusions For preventing HF progression is required additional research focused on cooperative care between GP and specialised HF outpatient clinic. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Supported by grant from the Slovak Society of Cardiology 2015 Selective screening of heart failure stages in regional settings