Screening to prevent heart failure (STOP‐HF): expanding the focus beyond asymptomatic left ventricular systolic dysfunction

Abstract

AimsWe evaluated the extent to which left ventricular diastolic dysfunction (LVDD) contributes to the high false-positive rates observed when natriuretic peptides (NPs) are used to screen for left ventricular systolic dysfunction (LVSD), and the use of NPs in combination with electrocardiogram (ECG) to screen for pre-clinical ventricular dysfunction (PCVD). Methods and resultsEight hundred and fourteen patients over 40 years of age and with at least one cardiovascular risk factor were recruited. Screening strategies for LVSD included brain natriuretic peptide (BNP) alone at cut-offs of 20, 50, and 100 pg/mL, and BNP and abnormal ECG combined. Systolic and diastolic function was assessed by Doppler echocardiography. A left ventricular ejection fraction (LVEF) of ,50% was present in 33 (4.1%) of subjects, while 11 (1.4%) had LVEF ,40%. At a cut-off of 20, 50, and 100 pg/mL, sensitivity for BNP alone when screening for LVSD was 88, 70, and 45%, and specificity 46, 77, and 90%, respectively. Of those labelled 'false positive' in the 20, 50, and 100 pg/mL cut-off groups, 26, 46, and 65%, respectively, were found to have significant LVDD (left atrial volume index .34 mL/m 2 ). Optimal sensitivity (80%) and specificity (72%) for PCVD was obtained when BNP at a cut-off of 50 pg/mL or an abnormal ECG were defined as a positive screen so that only this group would be sent for Doppler echocardiography. ConclusionsA significant number of patients at risk for LVSD and labelled false positive with screening were found to have LVDD. Identifying this at-risk cohort may improve outcomes, but the clinical and economic benefit of this screening strategy requires formal assessment.--

NT-proB natriuretic peptide, risk factors and asymptomatic left ventricular dysfunction: Results of the SCReening Evaluation of the Evolution of New Heart Failure Study (SCREEN-HF)

“…While a low plasma NT-proBNP level essentially excludes structural heart disease [39], Murtagh and the STOP-HF investigators examined the proportion of diastolic dysfunction responsible for the high rates of false positives when using BNP to screen for systolic dysfunction in an asymptomatic population (≥40 years + HF risk factor) [51]. They observed a significant proportion of diastolic dysfunction in those labeled as "false positives".…”

Influence of diabetes on natriuretic peptide thresholds in screening for Stage B heart failure

“…Such a group are patients with features of asymptomatic left ventricular abnormalities (Stage B Heart Failure). Previous work from our unit and others have shown that, while limitations exist, natriuretic peptide (NP) is an effective screening tool to identify this population (Vasan et al, 2002, Murtagh et al, 2012, Lubien et al, 2002, Nadir et al, 2015, Chahal et al, 2015, Hebert et al, 2010. In addition, risk stratification with NP can facilitate strategies guided by NP, which have been shown to be effective in reducing new onset heart failure and other cardiovascular (CV) events , Huelsmann et al, 2013.…”

ECG as a first step in the detection of left ventricular systolic dysfunction in the elderly

“…Chronic left ventricular systolic dysfunction (LVSD) represents the final stage in most heart diseases. It has a prevalence of 2% of the entire population and 10% of the geriatric population (75+), many asymptomatic, undetected, and untreated . The number of senior citizens increases, and consequently LVSD also increases …”

“…LVSD may severely affect functional capacity, life‐quality, and prognosis, but treatments are capable of improving morbidity and mortality, even in the asymptomatic . However, LVSD is under‐diagnosed and under‐treated in the elderly, especially in elderly women and screening for LVSD is mandatory to improve treatment of senior citizens and to alleviate symptoms, delay progression, and improve prognosis …”

“…They reflect anatomy, physiology, and electro‐physiology, and LVSD is associated with an abnormal ECG and elevated NT‐proBNP. ECG and NT‐proBNP have independent diagnostic utility, and the combination of ECG and NT‐proBNP seems to improve screening for LVSD . However, there has been little attempt to categorize the ECG abnormalities that may occur in LVSD, and to correlate ECG parameters and NT‐proBNP, and there has not been as yet a systematic exploration as to what combinations of ECG incides and NT‐proBNP could accomplish in diagnosing LVSD …”