Delays in echocardiography and diagnosis are related to adverse outcomes in suspected HF

ESC Heart Failure 2024 - Only 29% of the patients presenting to outpatient care with suspected HF had received an HF diagnosis after 1 year. Patients with suspected HF had higher risks of HF hospitalization and all-cause mortality than matched controls.

This summary is based on the presentation of Lisa Anderson, MD (London, UK) at the ESC Heart Failure Congress 2024 - Suspected de novo heart failure in outpatient care: high mortality and morbidity rates (REVOLUTION HF).

Introduction and methods

To reduce morbidity and mortality in patients with de novo HF, prompt diagnosis and treatment are needed. However, initiation of guideline-directed medical therapy (GDMT) is often delayed until echocardiography and specialist assessment have been performed. The 2023 clinical consensus statement of the ESC Heart Failure Association proposes to use NT-proBNP levels, in addition to clinical HF features, as a rule-in test for HF diagnosis.

To determine the risk profile of patients with suspected de novo HF, the researchers conducted a case-control study using linked Swedish nationwide medical data and cause of death records from 2015 through 2020. They included 5942 patients presenting to outpatient care with an HF sign (peripheral edema) and/or HF symptom (dyspnea), as well as NT-proBNP ≥300 ng/L within approximately 30 days of presentation, and 2048 age- and sex-matched controls who presented to outpatient care for any reason other than HF signs or symptoms. For the first group, the index date was the day when the HF sign and/or symptom and NT-proBNP measurement were on record.

The study outcomes were changes in medication use and the incidence of events, including HF hospitalization, all-cause mortality, time to first HF diagnosis, and time to first echocardiogram, at 1 year.

Main results

• While the NT-proBNP test result was available within 1 day for most patients with suspected de novo HF, the median time to the first registered echocardiogram was 40 days.
• After 1 year, 29% of the patients with suspected HF had received an HF diagnosis.
• After the index date, loop diuretic use increased immediately, but the uptake was much slower for RAASis, MRAs, beta-blockers, and SGLT2 inhibitors (if available during study period). • In the first weeks after the index date, the risks of HF hospitalization and all-cause mortality among patients with suspected HF were high, and they further accumulated over the year, especially in those with NT-proBNP >2000 ng/L.
• The cumulative incidence of HF hospitalization was 16.1 events per 100 patient-years in patients with suspected HF and 2.2 events per 100 patient-years in matched controls, whereas the cumulative incidence of all-cause mortality was 10.3 and 6.5 events per 100 patient-years, respectively.
• Both age and NT-proBNP levels were associated with increased rates of HF hospitalization and all-cause mortality.

Conclusion

Patients presenting to outpatient care with suspected de novo HF had higher risks of HF hospitalization and all-cause mortality than matched controls, which was already apparent in the first weeks after the index date. Although NT-proBNP testing was performed promptly, there was a delay in echocardiography and only 29% of the patients with suspected HF had received an HF diagnosis after 1 year. Except for loop diuretics, the uptake of GDMT was limited in the first year.

According to Dr. Anderson, “[t]hese findings highlight the need for a revolution in establishing a pragmatic ‘NT-proBNP rule-in’ approach to HF diagnosis that avoids the need to wait for phenotyping by echo. [In addition, a] low threshold for GDMT initiation needs to be adopted to [reduce] morbidity and mortality.”

- Our reporting is based on the information provided at the ESC Heart Failure Congress 2024 -