Natriuretic Peptide–Based Screening and Collaborative Care for Heart Failure: The STOP-HF Randomized Trial

Study Questions:

What is the impact of a brain-type natriuretic peptide (BNP)-based screening and intervention initiative on the prevalence of left ventricular (LV) dysfunction with or without newly diagnosed heart failure (HF) in an at-risk population?

Methods:

STOP-HF (St. Vincent’s Screening to Prevent Heart Failure Study) was a parallel-group, prospective, randomized study involving 1,374 participants from Ireland who were followed for a mean of 4.2 years. Eligible patients had one or more of the following risk factors: hypertension, hypercholesterolemia, obesity, vascular disease, diabetes mellitus, arrhythmia requiring therapy, or moderate to severe valvular disease. The primary endpoint was the prevalence of LV dysfunction (defined as any combination of an LV ejection fraction <50% or an E/E’ >15 in the setting of normal LV ejection fraction on Doppler echocardiography) with or without newly diagnosed HF. The control group received routine primary care management. The intervention group received BNP-driven collaborative care between the primary care physician and specialist cardiovascular center if the BNP was 50 pg/ml. The specialist intervention was multidimensional and included risk factor modification (including coaching by a specialist nurse) and prescription of the most appropriate therapy.

Results:

The primary endpoint of LV dysfunction and HF was met in 59 (8.7%) of 677 control-group patients and 37 (5.3%) of 697 intervention-group patients (odds ratio, 0.55; 95% confidence interval [CI], 0.37-0.82; p = 0.003). The incidence rates of emergency hospitalization for major cardiovascular events were 40.4 per 1,000 patient-years in the control group versus 22.3 per 1,000 patient-years in the intervention group (incidence rate ratio, 0.60; 95% CI, 0.45-0.81; p = 0.002).

Conclusions:

Among at-risk patients, a BNP-based screening strategy reduced the prevalence of LV dysfunction and HF.

Perspective:

The authors presented a unique randomized study of BNP-guided collaborative care and demonstrated a reduction in the primary endpoint in the intervention group. While there is an imperative to develop strategies to prevent progression of cardiovascular disease in patients with stage A HF, there are a number of limitations in this analysis, as acknowledged by the authors. In particular, the intervention group received multidisciplinary care (if BNP >50 pg/ml). Certainly this multidisciplinary care (independent of BNP levels) may have contributed to better outcomes in the intervention group. It is ultimately unclear what aspects of the specialist intervention may have impacted the outcomes. Furthermore, the CIs around the primary endpoint were particularly wide. BNP may have a role in stratification of patients at risk for developing HF. The findings from this study warrant further validation before BNP should be considered for screening in an at-risk population.

Clinical Topics: Heart Failure and Cardiomyopathies, Noninvasive Imaging, Acute Heart Failure, Heart Failure and Cardiac Biomarkers, Echocardiography/Ultrasound

Keywords: Heart Diseases, Incidence, Natriuretic Peptides, Ventricular Dysfunction, Biological Markers, Cardiology, Heart Failure, Cardiovascular Diseases, Risk Factors, Ireland, Echocardiography


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