Approaches to Preventing Heart Failure

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The HCPLive Peer Exchange: Advances in Heart Failure Management features expert opinion and analysis from leading physician specialists on the latest developments in heart failure research, diagnosis, and management.

This Peer Exchange is moderated by Peter Salgo, MD, professor of medicine and anesthesiology at Columbia University and an associate director of surgical intensive care at the New York-Presbyterian Hospital in New York City.

The panelists are:

• Michael Felker, MD, MHS, Professor of Medicine, Chief of the Heart Failure Section, Director of the Heart Center Clinical Research Unit, and Director of the Advanced Heart Failure Fellowship at Duke University School of Medicine
• Jim Januzzi, MD, Roman W. DeSanctis Endowed Distinguished Clinical Scholar in Medicine at Massachusetts General Hospital and Hutter Professor of Medicine at Harvard Medical School
• Christian Schulze, MD, PhD, Associate Professor of Medicine, Division of Cardiology at Columbia University Medical Center, and Director of Research for the Center of Advanced Cardiac Care at Columbia University Medical Center

In this segment of the Peer Exchange, the panelists discuss recent studies and other research aimed at identifying patients at higher risk for heart failure who might benefit from intensive preventive measures. They also discuss biomarkers and other potential clinical indicators of heart failure risk.

Dr. Felker points out that the portion of people at risk for heart failure “is huge, so doing an intensive strategy in that entire population is impractical… you have to figure out how can you narrow it down to the people who are at really high risk [for heart failure] and there are several interesting strategies which have been purported like for example, using biomarkers like high-sensitivity troponin or the natriuretic peptides.”

These methods have been tested in observational studies like Framingham, the Physician’s Health Study, and the Cardiovascular Health Study. Now, according to Dr. Felker, we’re seeing the first wave of clinical trials that are actually testing a heart failure prevention strategy (eg, the STOP-HF trial that was published in JAMA last year). In that trial, researchers showed that, in a primary care setting, you can actually prevent heart failure by identifying the high-risk people and aggressively pursuing [prevention] strategies.”

Dr. Januzzi says that the STOP-HF investigators identified patients with well-described clinical risk factors for heart failure (hypertension, diabetes, etc) which “are not specific enough to identify an absolute likelihood for heart failure,” and then tested the hypothesis that a biomarker concentration (highly-sensitive troponin, ST2, and other markers) “could identify those patients that have the risk factors, so-called ACC/AHA Stage A heart failure, and flag them as having the molecular process that’s bridging them from at-risk to symptomatic heart failure.”

Dr. Salgo points out that this approach is “fairly technical and laboratory intensive” and asks what are some red flags the average busy clinician can look for.

Dr. Januzzi says that, as the Framigham Study showed, everyone who does not currently have heart failure faces a 20-25% lifetime risk. Still, he says the risk factors to look for are the ones previously identified: patients with elevated blood pressure, coronary artery disease, and valvular heart disease. “These are more common in men,” Dr. Januzzi says. In women, “diabetes jumps up further up in the list and that’s partially because women more often tend to have preserved ejection fraction heart failure, which is characteristic of the so-called hypertensive phenotype,. So they tend to have small hearts that are hypertrophied with diastolic noncompliance. There are differences, but the numbers are quite staggering in terms of the likelihood for onset.”