High mortality and morbidity in suspected de novo HF in outpatient care

The REVOLUTION-HF study of patients with suspected de novo heart failure (HF) presenting to outpatient centres showed that echocardiography was often delayed, and only a minority of patients received a diagnosis of HF. There was little increase in uptake of guideline-directed medical therapy following presentation for suspected de novo HF, and the risk of HF hospitalisation and all-cause mortality was high.

Prompt identification, diagnosis, and treatment initiation in patients with de novo HF are needed to improve morbidity and mortality. Diagnosis is often delayed until echocardiography and specialist consultation is performed, which delays the provision of life-saving, evidence-based medication.

“This study aimed to look at the risk profile of people presenting with HF signs and symptoms and with an elevated NT-proBNP,” said Dr Lisa Anderson (St George’s Healthcare NHS Foundation Trust, UK) [1]. The researchers assessed changes in treatment and clinical events of 5,942 participants presenting to an outpatient clinic in Sweden with suspected HF and NT-proBNP levels >300 ng/L between 2015 and the end of 2020. This cohort was compared with 2,048 matched controls who presented for reasons unrelated to HF.

Overall, only 29% of participants with suspected de novo HF received a diagnosis of HF in the year following the index date. “The waits for echocardiography and diagnosis were very disappointing,” said Dr Anderson, “even in the group with the highest baseline NT-proBNP of over 2,000 ng/L.” Although Dr Anderson was impressed with the prompt NT-proBNP testing, which usually yielded a result within 24 hours, she found that changes in treatment were also suboptimal. In case of suspected HF, the use of loop diuretics almost quadrupled, but there was little increase in guideline-directed medical therapy, including prescription of beta-blockers, renin‐angiotensin system inhibitors, and mineralocorticoid receptor antagonists.

Compared with matched controls, participants with suspected HF had higher rates of HF hospitalisation and all-cause mortality (see Figure). The risks were high during the first weeks after the index and increased with rising NT-proBNP.

Figure: Risk of HF hospitalisation and all-cause mortality following suspected de novo HF [1]



HF, heart failure; PY, patient-years.

According to Dr Anderson, these findings highlight the need for a revolution in establishing a pragmatic ‘NT-proBNP rule-in’ approach to HF diagnosis to avoid the need to wait for phenotyping by echocardiography. She also advocated the adaptation of a low threshold for guideline-directed medical therapy initiation to improve morbidity and mortality in patients with suspected de novo HF. Further study is needed for an NT-proBNP rule-in approach to the diagnosis and management of HF.

1. 
   
   1. Anderson L, et al. Suspected de novo heart failure in outpatient care: high mortality and morbidity rates (REVOLUTION HF). Late-breaking clinical trials I, Heart Failure 2024, 11–14 May, Lisbon, Portugal.

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Posted on 16 July 202416 July 2024