Recognizing Risk Factors to Mitigate Pre-Heart Failure

Dr Januzzi analyzes preventive approaches for patients with pre-heart failure, including comorbidity considerations and preliminary testing.

Ryan Haumschild, PharmD, MS, MBA: What are some of the characteristics of someone who has pre-heart failure, however you want to define that, and some of the unique considerations that you want to give to those patients to stop the progression?

Jim Januzzi, MD: Thank you so much. It’s a testament to the evolution of the guidelines that we’re thinking about prevention. I’d love to be out of a job and not have to see patients with symptomatic heart failure. For what it’s worth, there’s definitely a push toward recognizing risk and intervening. Stage A heart failure describes individuals with a single or multiple risk factors but without congestion or abnormalities in cardiac function. That includes the presence of hypertension, type 2 diabetes, and type 1 diabetes. It includes having risk factors for heart failure without cardiac dysfunction—a huge number of patients. Adhering to the data that we know can reduce risk for heart failure, treatment of hypertension, treatment of diabetes, and addressing chronic kidney disease before it progresses, are critically important.

An equally important population are those with pre-heart failure, which is strictly defined as stage B heart failure. Pre-heart failure includes people with cardiac dysfunction, so left ventricular dysfunction, left ventricular hypertrophy, dilated chambers, reduced ejection fraction without symptoms, or an elevated natriuretic peptide or high-sensitivity troponin. This is an important population of patients because they’re at very high risk of progression to symptomatic heart failure.

There are certain paradigms for this category of patients. I’ll give you one very important one: the patient with diabetes. The reason we know this is the case is because of data from recent cardiovascular outcomes trials in diabetes where individuals with type 2 diabetes and an elevated natriuretic peptide but without symptoms of heart failure had a more than a 5-fold increased risk of progression to symptomatic failure within a 2- to 3-year period.

Treatment with an SGLT2 inhibitor in this population of patients reduced the risk for heart failure substantially—so substantially that the American Diabetes Association recently published a consensus document recommending yearly screening of individuals with chronic diabetes with either NT-proBNP or high sensitivity troponin with the expressed goal of detecting the presence of stage B heart failure and push individuals toward treatment with drugs like SGLT2 inhibitors. There’s a big focus on prevention, which one would hope would slow the rising tide of heart failure that we continue to see in modern cardiology.

John E. Anderson, MD: Dr Januzzi’s point is extremely well made. Who thought we would have American Diabetes Association guidelines looking like ACC [American College of Cardiology] guidelines, AHA [American Heart Association] guidelines, and not to mention CKD [chronic kidney disease] guidelines? In primary care, we haven’t traditionally done a great job of picking up the subtleties of patients who have early, presymptomatic heart failure. We tend to see obese patients and dismiss the fact that they’re short of breath. We think we understand why they’re short of breath. We dismiss a bit of edema as venous insufficiency. His point is extremely valid. It’s incumbent upon us to listen to our patients, examine them, get a proBNP, and get an echocardiogram if necessary, and find these patients long before their first hospitalization.

Transcript edited for clarity.

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