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Detection and management of preclinical heart failure

Detection and management of preclinical heart failure. Tom Marwick. Director, Menzies Research Institute Tasmania. EARLY HEART FAILURE Preclinical heart failure. Overt heart failure (Stages C and D). Preclinical disease Stage B.

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Detection and management of preclinical heart failure

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  1. Detection and management of preclinical heart failure Tom Marwick Director, Menzies Research Institute Tasmania

  2. EARLY HEART FAILUREPreclinical heart failure Overt heart failure (Stages C and D) Preclinical disease Stage B Risk factors including social determinants and behaviour (Stage A)

  3. EARLY HEART FAILUREHF stages Stage A At high risk for HF without structural heart disease or symptoms Stage B Structural heart disease but without signs or symptoms of HF Stage C Structural heart disease with prior or current symptoms of HF Stage D Refractory HF requiring specialized intervention Patient with: -Previous MI -LV remodeling including LVH and low EF -Asymptomatic valvular disease Patient with: -Hypertension -Atherosclerosis -Diabetes -Metabolic syndrome -Cardiotoxins -With FHxCM Hunt SA, et al. J Am Coll Cardiol 2009;53:e1-e90

  4. EARLY HEART FAILURETCF funding – Rural HF project • Why - The epidemiology of heart failure • Detection - is HF screening an option? • Right population • Right test • Rx strategy • Measuring outcomes • Quantifying risk, FP and FN results • Proof of Principle – TasELFstudy • Lessons about community-based RCTs

  5. EARLY HEART FAILUREWhat is heart failure? Chronic heart failure Acute heart failure

  6. EARLY HEART FAILUREMagnitude of the Problem Australia (National Heart Foundation of Australia-HF guideline) • Prevalence: 10% (> 65 yrs); 50% (> 85 yrs ) • Annual Incident HF: 30,000 • Annual admissions: 100,000 • Annual cost of care: $411 million (0.4% ) USA (Hunt SA ,2009) • Prevalence: 5,800,000 • Incident rate: 500,000 /year • Annual cost of care: 39 billion (1-2%) Worldwide (McMurray JJ 1998) • Prevalence: 23,000,000

  7. EARLY HEART FAILUREThe heart failure epidemic HF IS THE SINGLE MOST EXPENSIVE DIAGNOSIS IN HEALTH SYSTEM Hospital admissions per 1,000 population per year for heart failure (Kannel WG. Br Heart J 1994) Chance of getting HF? - About 30% • Why is HF increasing? • - Aging • - Survival from heart attack • - Risk factors • BP • diabetes • obesity

  8. EARLY HEART FAILUREMetabolic drivers of the HF epidemic Wellcome Museum, London

  9. EARLY HEART FAILUREHF – Survival rate at 5 years Stewart S, et al. More malignant than cancer? Five-year survival following a first admission for heart failure in Scotland. European Journal of Heart Failure 3 (2001) 315-322

  10. EARLY HEART FAILURE Heart Failure - Quality of Life PF: Physical function RP: Role limitation BP: Body pain GH: General health perceptions VT: Vitality SF: Social function RE: Emotional Problems MH: Mental Health Lynn J. JAMA 1997; 277:1633-40 Juenger J et al. Health related quality of life in patients with congestive heart failure: comparison with other chronic disease and relation to functional variables. Heart 2001; 87: 235

  11. EARLY HEART FAILUREHF is bad! What can we do about it? Focus on early disease to change trajectory

  12. EARLY HEART FAILURETCF funding – Rural HF project • Why - The epidemiology of heart failure • Detection - is HF screening an option? • Right population • Right test • Rx strategy • Measuring outcomes • Quantifying risk, FP and FN results • Proof of Principle – TasELFstudy • Lessons about community-based RCTs

  13. EARLY HEART FAILUREScreening for HF • Prevalence: 10% (> 65 yrs) • At June 2010, there were 79,100 people aged 65 years and over in Tasmania - 15.6% of the population • Can we afford to screen ~80,000 people in order to find ~8,000 with HF?

  14. EARLY HEART FAILUREWhat’s wrong with screening? • The risk of false positive results • Lead to further unnecessary diagnostic testing, over-treatment, some can be invasive • Cause psychological distress and anxiety in asymptomatic people • Need of evidence that screening and detection changes management outcomes Screening for Heart Failure has not been recommended by the US Preventive Services Task Force

  15. EARLY HEART FAILUREEssentials of screening Thomas Bayes, 1702-61 Choosing the right population Having the right test Absolute vs relative risk Defining the phenotype Having a treatment strategy Knowing how to manage false positive and false negative tests

  16. EARLY HEART FAILURERural HF project • Why - The epidemiology of heart failure • Detection - is HF screening an option? • Right population • Right test • Rx strategy • Measuring outcomes • Quantifying risk, FP and FN results • Proof of Principle – TasELFstudy

  17. EARLY HEART FAILUREShrink the haystack

  18. EARLY HEART FAILUREFramingham HF Risk Score

  19. EARLY HEART FAILUREHealth ABC HF Score

  20. EARLY HEART FAILURE ARIC HF Risk Score

  21. Total articles identified (n=2947) EARLY HEART FAILUREPRISMA- A Meta Analysis Excluded duplicates (n=973) Articles reviewed by title or abstract (n=1974) Excluded by title or abstract (n=1880) Inclusion: Study in unselected population, community Reporting risk effect size in RR/OR/HR Outcome: incident heart failure Articles eligible for review (n=94) 18 additional articles from bibliographies included. Articles for full text review (n=111) Excluded articles not reporting characteristics of inclusion criteria (n=83) Articles included in systematic review (n=29) Excluded articles reporting risk inconsistent with inclusion criteria (n=6) Articles included for meta-analysis (n=23)

  22. EARLY HEART FAILUREStudies included

  23. EARLY HEART FAILURERisk variables identified

  24. Risk Variable -Hypertension

  25. EARLY HEART FAILUREInclusion/ Exclusion Inclusion • > 65 years • Diabetes • High blood pressure /on treatment • Overweight • Family history of heart failure • Past history of chemotherapy • Past history of heart disease Exclusion • < 65 years • > Moderate valve disease • History of heart failure • Already on BB and ACEi • Contraindications to BB or ACEi • Oncologic life expectancy <12 month • Inability to acquire adequate images

  26. EARLY HEART FAILURERural HF project • Why - The epidemiology of heart failure • Detection - is HF screening an option? • Right population • Right test • Rx strategy • Measuring outcomes • Quantifying risk, FP and FN results • Proof of Principle – TasELFstudy • Lessons about community-based RCTs

  27. EARLY HEART FAILURE BNP release from Cardiac Myocytes preproBNP (134 aa) myocyte proBNP (108 aa) signal peptide (26 aa) secretion NT-proBNP (1-76) BNP (77-108)

  28. EARLY HEART FAILURE BNP to ER presentation with dyspnea N=139 N=14 N=97 Maisel A. J Am Coll Cardiol 2001

  29. p<0.05 p<0.05 EARLY HEART FAILURE Preclinical disease and BNP n=101 apparently normal diabetic subjects (asymptomatic, normal EF) BNP in LVH pts was higher than those without LVH But only 4 had elevated BNP (using age and gender-specific normal ranges) - only 1 had low velocity/strain BNP is not a good marker of subclinical disease (no substitute for the echo lab!) Fang ZY. Am Heart J 2005 NT-proBNP (pg/ml) Taylor A. Am Heart J 2006

  30. EARLY HEART FAILUREEcho is essential in HF diagnosis Siemens SC2000 Philips ie33 GE Vivid e9

  31. EARLY HEART FAILUREProgressive miniaturization

  32. EARLY HEART FAILUREEarly HF – Standard tests normal LA volume 32ml/m2

  33. EARLY HEART FAILUREMeasurement of strain

  34. 1.3 S-1 0.7 S-1 EARLY HEART FAILUREStrain and sick heart muscle

  35. EARLY HEART FAILUREOther diagnostic markers? • Central Blood Pressure • ECG • 6 Minute-walk Test (6MW) • Assessment of Activity and quality of life • Minnesota MLHFQ score • Charlson comorbidity index • Duke Activity Status Index (DASI) • EQ5D • SOF frailty score

  36. EARLY HEART FAILURERural HF project • Why - The epidemiology of heart failure • Detection - is HF screening an option? • Right population • Right test • Rx strategy • Measuring outcomes • Quantifying risk, FP and FN results • Proof of Principle – TasELFstudy

  37. Stage B Heart failurecardio-protective Treatment (SOLVD trial) SOLVD – Prevention Trial Study of Left Ventricular Dysfunction percentage of event, defined as death or hospitalization for congestive Heart Failure, occurring in the placebo and Enalapril (ACEi) Groups

  38. Cardio-protective Treatment of Stage B Heart failure (SAVE trial) SAVE Trial - Captopril Study of Survival and Ventricular Enlargement Trial

  39. EARLY HEART FAILURE Rural HF project • Why - The epidemiology of heart failure • Detection - is HF screening an option? • Right population • Right test • Rx strategy • Measuring outcomes • Quantifying risk, FP and FN results • Proof of Principle – TasELF study

  40. EARLY HEART FAILUREStage B HF - Progression to overt HF Aaron M. From et al. The development of Heart Failure in Patients with Diabetes Mellitus and Preclinical Diastolic Dysfunction: A Population Based Study. JACC 2010 26; 55(4) • Natural history of SBHF • Olmsted County study (n=1760) • LV dysfunction in T2DM • 25% HF in 2 years, 36.9% in 5 years, twice the rate of HF in patients without LV dysfunction

  41. EARLY HEART FAILURERural HF project • Why - The epidemiology of heart failure • Detection - is HF screening an option? • Right population • Right test • Rx strategy • Measuring outcomes • Quantifying risk, FP and FN results • Proof of Principle – TasELF study

  42. EARLY HEART FAILUREChanges needed Medicare TasmaniaMedicare Local DHHS THOs “55113 – Cardiac M-mode and 2 dimensional real time echocardiographic examination of the heart … for the investigation of symptoms or signs of cardiac failure, or suspected or known ventricular hypertrophy or dysfunction, or chest pain”

  43. EARLY HEART FAILURE Research Questions • 1. What is the prevalence of Stage B Heart Failure (LVSD & LVDD) in at risk population in Tasmanian community • 2. How does functional capacity (6MW test) correlates with echo systolic and diastolic parameters • 3. How does central blood pressure associate with diastolic dysfunction and LV mass • 4. What is a better echo marker LVEF, GLS and diastology in stage B heart failure. • 5. How does screening and early treatment affect quality of life? • 6. Is community screening cost effective? • 7. What are the main constrains of a community screening model? Main constrains of treatment delivery.

  44. TASELF - Study design

  45. TASELF Planned sites Hobart Huonville Oatlands Geeveston Longford Deloraine Launceston Smithton Ulverstone George Town Devonport New Norfolk Sorrell Kingston Scottdale Queenstown St Helen’s

  46. EARLY HEART FAILUREHow we will screen for HF

  47. EARLY HEART FAILUREPlanned protocol Clinical questionnaires Baseline echo HF 25% Usual care Randomize 1:1 (n=800) Apparently healthy subject with HF risk Clinically suitable for randomization Normal LV HF 10% Echo strain, diastology Exclusion of known HF, co-morbidities, CAD Exclusion of reduced EF (<40%), valve disease, CAD BNP in borderline 2 year follow-up for HF and functional capacity Subclinical LVD – start ACEi and BB (n=120) HF 5% Aim to study 800 subjects in the 1st year (400 subjects with HF screening and therapy vs 400 controls) ~16 studies per week (ie 2 trips/week)

  48. TASELF Registry – updated May 2014

  49. EARLY HEART FAILUREThe Big Picture • At June 2010, there were 79,100 people aged 65 years and over in Tasmania - 15.6% of the population • The prevalence of people in this age group with diabetes (T2DM), obesity, high blood pressure, past cancer therapy or known cardiac disease is about 50% - roughly 40,000 people (100 times the number in the study) • An effective program on a state-wide basis would avoid/delay heart failure in 2,400 people.

  50. EARLY HEART FAILUREStakeholders

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