Produção Nacional
Revisado por pares
Prevention of “Failure”
2018; Lippincott Williams & Wilkins; Volume: 137; Issue: 2 Linguagem: Inglês
10.1161/circulationaha.117.030645
ISSN1524-4539
AutoresVijay Nambi, Anita Deswal, Christie M. Ballantyne,
Tópico(s)Acute Myocardial Infarction Research
ResumoHomeCirculationVol. 137, No. 2Prevention of "Failure" Free AccessArticle CommentaryPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessArticle CommentaryPDF/EPUBPrevention of "Failure"Is It a Failure of Prevention? Vijay Nambi, MD, PhD, Anita Deswal, MD, MPH and Christie M. Ballantyne, MD Vijay NambiVijay Nambi Department of Medicine, Michael E. DeBakey Veterans Affairs Hospital, Houston, TX (V.N., A.D.) Sections of Cardiology (V.N., A.D., C.M.B.) Cardiovascular Research (V.N., C.M.B.) Department of Medicine, Baylor College of Medicine, Houston, TX. Houston Methodist DeBakey Heart and Vascular Center, TX (V.N., C.M.B.). , Anita DeswalAnita Deswal Department of Medicine, Michael E. DeBakey Veterans Affairs Hospital, Houston, TX (V.N., A.D.) Sections of Cardiology (V.N., A.D., C.M.B.) and Christie M. BallantyneChristie M. Ballantyne Sections of Cardiology (V.N., A.D., C.M.B.) Cardiovascular Research (V.N., C.M.B.) Department of Medicine, Baylor College of Medicine, Houston, TX. Houston Methodist DeBakey Heart and Vascular Center, TX (V.N., C.M.B.). Originally published9 Jan 2018https://doi.org/10.1161/CIRCULATIONAHA.117.030645Circulation. 2018;137:106–108The onset of symptomatic heart failure (HF) remains associated with a poor prognosis despite many advances in therapies and enormous resources spent on both treatment and research for advanced symptomatic HF. Therefore, prevention of HF is critical. Reviewing and mirroring successful strategies that have helped in the prevention of atherosclerotic cardiovascular disease (ASCVD), in which significant advances have been made in recent decades, may help guide our efforts in preventing HF.Quantitative assessment of an individual's ASCVD risk with tools such as the Framingham Risk Score has been used in guidelines throughout the world as the initial step to guide the intensity of risk factor modification with lifestyle and drug therapy. After initial efforts in classifying individuals at risk for HF as stage A/B resulted in the majority of individuals being classified as at risk, HF-specific clinical risk scores were recently developed; however, most primary care providers and even cardiologists are unaware of their existence. The 2013 American College of Cardiology/American Heart Association HF guidelines do not endorse any specific risk assessment tool, but the 2017 update and the recent American Heart Association scientific statement review the potential value of biomarkers in HF risk assessment.These advances in HF risk estimation using algorithms that include biomarkers allow quantitative identification of higher-risk individuals. Multiple studies, including the Atherosclerosis Risk in Communities study, have shown the value of candidate biomarkers such as troponin T (measured with a highly sensitive assay) and NT-proBNP (N-terminal pro–B-type natriuretic peptide) in predicting HF risk.1 In fact, of the outcomes studied (ASCVD, death, and HF), the best prediction performance was for HF, not ASCVD. A laboratory model (including age, sex, race, troponin T, and NT-proBNP) developed subsequently was as powerful as clinical scores in predicting HF risk and can be reported with laboratory test results,2 similar to estimated glomerular filtration rate. Other biomarkers (eg, galectin-3, ST2) and genes are under evaluation. Advances in imaging now allow better study of the relaxation and stiffness of the heart and blood vessels and the interaction between the heart and blood vessels. Hence, routine HF risk assessment in clinical practice needs to be endorsed, encouraged, and emphasized because it is now possible, with the guidance of biomarkers and imaging, to identify individuals at higher risk of HF with greater precision.Considerable controversy arose when the American College of Cardiology/American Heart Association risk calculator was introduced in 2013 as to whether it overestimated risk for ASCVD events (expanded to include stroke in addition to myocardial infarction). Unfortunately, this reflects the myopic view that preventive cardiology is limited to ASCVD. How can a patient–physician discussion not include risk for developing HF when incident HF hospitalization is more frequent than incident stroke and myocardial infarction combined? Atrial fibrillation may also need to be considered in an expanded definition of cardiovascular diseases (CVDs).Global risk scores that include outcomes of HF along with ASCVD have been recently described.3 Routine provision of global CVD risk in addition to coronary heart disease–, stroke-, and HF-specific risk may help direct global and disease-specific preventive strategies as they emerge (Figure). A global risk estimate could spur an individual to improve his/her lifestyle, and disease-specific risk could direct therapy targeting risk factors common to CVDs. For example, treatment of an individual at higher risk for HF may include a DASH–style diet (Dietary Approaches to Stop Hypertension), a diuretic for hypertension, and perhaps a medication such as empagliflozin for diabetes mellitus and avoidance of a pure α-blocker.Download figureDownload PowerPointFigure. A framework to approaching comprehensive primary prevention of global cardiovascular disease (CVD) risk with a focus on component CVD. ASCVD indicates atherosclerotic cardiovascular disease; BP, blood pressure; CHD, coronary heart disease; HF, heart failure; MI, myocardial infarction; and SGLT2, sodium/glucose cotransporter 2.Part of the clinical inertia in risk assessment may be the lack of an answer to a clinician's question, "What would I do with this information?" Thus far, no unique therapies prevent HF. However, recent studies testing biomarker-based approaches may provide guidance. For example, the STOP-HF study (St. Vincent's Screening to Prevent Heart Failure) reported improved outcomes in individuals with BNP >50 pg/mL randomized to receive an echocardiogram with cardiology evaluation versus usual care.4 BNP–based screening and collaborative care reduced combined rates of left ventricular dysfunction with or without HF and the incidence of emergency hospitalization for major cardiovascular events. Similarly, the PONTIAC trial (NT-proBNP Selected Prevention of Cardiac Events in a Population of Diabetic Patients Without a History of Cardiac Disease) randomized 300 subjects with type 2 diabetes mellitus and NT-proBNP >125 pg/mL to regular care in diabetes care units or intensified care in which renin-angiotensin antagonists and β-blockers were uptitrated in a cardiology setting. Intensive treatment resulted in a significant reduction in the primary end point of hospitalization for any cardiac cause.5 We are now studying whether randomizing individuals with systolic blood pressure of 120 to 150 mm Hg and an estimated 10-year HF risk >5% to spironolactone or carvedilol will result in improved strain measurements on echocardiogram and improved vascular stiffness compared with usual care (ClinicalTrials.gov NCT02230891). A similar approach using echocardiogram-based strain measurements and acting on changes in this parameter is advocated in cancer chemotherapy.Primary prevention of HF currently has no clear home. In general, preventive cardiologists have focused on the prevention of ASCVD, whereas HF experts have focused on secondary prevention and management of HF. As a community, we need to pay greater attention and dedicate more resources to what is becoming the costliest CVD that cardiologists need to manage. Although HF has various causes and pathways, the greatest contributor to HF remains the traditional risk factors. We propose that the following strategies be considered and debated: (1) include HF routinely as a major adverse cardiovascular event and an end point in any study evaluating therapy for CVD, (2) include HF risk in estimating global CVD risk and report risk estimates for the component events (eg, stroke, HF, coronary heart disease), (3) implement dietary and antihypertensive strategies already shown to work, and (4) conduct clinical trials enriched with individuals at higher risk for HF (identified by risk scores) to test a strategy of more aggressive therapy compared with routine care (as was done in SPRINT [Systolic Blood Pressure Intervention Trial]) for HF prevention.AcknowledgmentsThe authors thank Kerrie Jara for her editorial assistance.DisclosuresDr Nambi reports the following: research grant, (site Principal Investigator) Merck; Regional Advisory Board (once), Sanofi Regeneron; co-investigator provisional patent (# 61721475) entitled, "Biomarkers to Improve Prediction of Heart Failure Risk," filed by Baylor College of Medicine, Roche; an honorarium, Siemens for event adjudication. Dr Nambi is supported by an Investigator-Initiated Research grant from the Department of Veterans Affairs Clinical Science Research & Development grant (1I01CX001112-01: Nambi V [PI] 04/01/2014-03/31/2019 Biomarker Guided Therapies in Stage A/B Heart Failure). Dr Deswal reports no conflicts. Dr Ballantyne reports the following: grant/research support–all significant (all paid to institution, not individual): Abbott Diagnostic, Amarin, Amgen, Ackea, Eli Lilly, Esperion, Novartis, Pfizer, Regeneron, Roche Diagnostic, Sanofi-Synthelabo, Takeda, NIH, AHA, ADA; Consultant– Abbott Diagnostics, Amarin, Amgen*, Astra Zeneca*, Ackea, Eli Lilly, Esperion, Matinas BioPharma Inc, Merck*, Novartis, Pfizer*, Regeneron, Roche, Sanofi-Synthelabo (*significant where noted [>$10 000]; remainder modest [<$10 000]); co-investigator provisional patent (# 61721475) entitled, "Biomarkers to Improve Prediction of Heart Failure Risk," filed by Baylor College of Medicine, Roche.FootnotesThe opinions expressed reflect those of the authors and not necessarily those of the Department of Veterans Affairs.Circulation is available at http://circ.ahajournals.org.Correspondence to: Vijay Nambi, MD, PhD, Baylor College of Medicine, One Baylor Plaza, 521D, MS 285, Houston, TX 77030. E-mail [email protected]References1. Saunders JT, Nambi V, de Lemos JA, Chambless LE, Virani SS, Boerwinkle E, Hoogeveen RC, Liu X, Astor BC, Mosley TH, Folsom AR, Heiss G, Coresh J, Ballantyne CM. Cardiac troponin T measured by a highly sensitive assay predicts coronary heart disease, heart failure, and mortality in the Atherosclerosis Risk in Communities Study.Circulation. 2011; 123:1367–1376. doi: 10.1161/CIRCULATIONAHA.110.005264.LinkGoogle Scholar2. Nambi V, Liu X, Chambless LE, de Lemos JA, Virani SS, Agarwal S, Boerwinkle E, Hoogeveen RC, Aguilar D, Astor BC, Srinivas PR, Deswal A, Mosley TH, Coresh J, Folsom AR, Heiss G, Ballantyne CM. Troponin T and N-terminal pro-B-type natriuretic peptide: a biomarker approach to predict heart failure risk: the Atherosclerosis Risk in Communities study.Clin Chem. 2013; 59:1802–1810. doi: 10.1373/clinchem.2013.203638.CrossrefMedlineGoogle Scholar3. de Lemos JA, Ayers CR, Levine B, deFilippi CR, Wang TJ, Hundley WG, Berry JD, Seliger SL, McGuire DK, Ouyang P, Drazner MH, Budoff M, Greenland P, Ballantyne CM, Khera A. Multimodality strategy for cardiovascular risk assessment: performance in 2 population-based cohorts.Circulation. 2017; 135:2119–2132. doi: 10.1161/CIRCULATIONAHA.117.027272.LinkGoogle Scholar4. Ledwidge M, Gallagher J, Conlon C, Tallon E, O'Connell E, Dawkins I, Watson C, O'Hanlon R, Bermingham M, Patle A, Badabhagni MR, Murtagh G, Voon V, Tilson L, Barry M, McDonald L, Maurer B, McDonald K. Natriuretic peptide-based screening and collaborative care for heart failure: the STOP-HF randomized trial.JAMA. 2013; 310:66–74. doi: 10.1001/jama.2013.7588.CrossrefMedlineGoogle Scholar5. Huelsmann M, Neuhold S, Resl M, Strunk G, Brath H, Francesconi C, Adlbrecht C, Prager R, Luger A, Pacher R, Clodi M. PONTIAC (NT-proBNP selected prevention of cardiac events in a population of diabetic patients without a history of cardiac disease): a prospective randomized controlled trial.J Am Coll Cardiol. 2013; 62:1365–1372. doi: 10.1016/j.jacc.2013.05.069.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Mahmood T and Shapiro M (2021)(2021)(2021) The Questions on Everyone's Mind: What is and Why Do We Need Preventive Cardiology?, Methodist DeBakey Cardiovascular Journal, 10.14797/mdcvj.698, 17:4, (8-14), Online publication date: 24-Sep-2021., Online publication date: 24-Sep-2021., . Shapiro M, Maron D, Morris P, Kosiborod M, Sandesara P, Virani S, Khera A, Ballantyne C, Baum S, Sperling L, Bhatt D and Fazio S (2019) Preventive Cardiology as a Subspecialty of Cardiovascular Medicine, Journal of the American College of Cardiology, 10.1016/j.jacc.2019.08.1016, 74:15, (1926-1942), Online publication date: 1-Oct-2019. Ballantyne C and Nambi V (2019) Seven Metrics That Will Determine Your Cardiovascular Success or Failure, JACC: Heart Failure, 10.1016/j.jchf.2019.04.008, 7:8, (648-650), Online publication date: 1-Aug-2019. Goyder C, Roalfe A, Jones N, Taylor K, Plumptre C, Fanshawe T, Hobbs F and Taylor C (2019) Diagnostic accuracy and clinical impact of natriuretic peptide screening for the detection of heart failure in the community: a protocol for systematic review and meta-analysis, Wellcome Open Research, 10.12688/wellcomeopenres.15536.2, 4, (169) Goyder C, Roalfe A, Jones N, Taylor K, Plumptre C, Hobbs F and Taylor C (2019) Diagnostic accuracy and clinical impact of natriuretic peptide screening for the detection of heart failure in the community: a protocol for systematic review and meta-analysis, Wellcome Open Research, 10.12688/wellcomeopenres.15536.1, 4, (169) Saeed A and Ballantyne C (2019) Future Directions in the Use of Biomarkers for Prevention of Cardiovascular Disease Biomarkers in Cardiovascular Disease, 10.1016/B978-0-323-54835-9.00016-8, (171-177), . Peterson P, Allen L, Heidenreich P, Albert N and Piña I (2018) The American Heart Association Heart Failure Summit, Bethesda, April 12, 2017, Circulation: Heart Failure, 11:10, Online publication date: 1-Oct-2018. Saeed A, Nambi V, Sun W, Virani S, Taffet G, Deswal A, Selvin E, Matsushita K, Wagenknecht L, Hoogeveen R, Coresh J, de Lemos J and Ballantyne C (2018) Short-Term Global Cardiovascular Disease Risk Prediction in Older Adults, Journal of the American College of Cardiology, 10.1016/j.jacc.2018.02.050, 71:22, (2527-2536), Online publication date: 1-Jun-2018. January 9, 2018Vol 137, Issue 2 Advertisement Article InformationMetrics © 2018 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.117.030645PMID: 29311345 Originally publishedJanuary 9, 2018 Keywordsheart failureprimary preventionPDF download Advertisement SubjectsHeart FailurePrimary Prevention
Referência(s)