Imaging-Guided Cardioprotective Treatment in a Community Elderly Population of Stage B Heart Failure

• Published in: JACC. Cardiovascular imaging Vol. 10; no. 3; pp. 217 - 226
• Main Authors: Yang, Hong, Negishi, Kazuaki, Wang, Ying, Nolan, Mark, Marwick, Thomas H.
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.03.2017
• Subjects: Adrenergic beta-Antagonists - adverse effects; Adrenergic beta-Antagonists - therapeutic use; Age Factors; Aged; Angiotensin-Converting Enzyme Inhibitors - adverse effects; Angiotensin-Converting Enzyme Inhibitors - therapeutic use; Cardiovascular; Clinical Decision-Making; community detection; Decision Support Techniques; Disease-Free Survival; Drug Therapy, Combination; Echocardiography, Doppler; Feasibility Studies; Female; Heart Failure - diagnostic imaging; Heart Failure - drug therapy; Heart Failure - mortality; Heart Failure - physiopathology; Humans; Intention to Treat Analysis; Kaplan-Meier Estimate; Male; Medication Adherence; medication nonadherence; Myocardial Contraction - drug effects; pharmacological intervention; Predictive Value of Tests; randomized controlled trial; Recovery of Function; stage B heart failure; Tasmania; Time Factors; Treatment Outcome; Ventricular Dysfunction, Left - diagnostic imaging; Ventricular Dysfunction, Left - drug therapy; Ventricular Dysfunction, Left - mortality; Ventricular Dysfunction, Left - physiopathology; BB; DD; A; EF; HTN; AE; AF; E; LV; SAHF; SBHF; UC; randomized controlled trial; GLS; medication nonadherence; ARB; CV; stage B heart failure; ACEi; community detection; pharmacological intervention; HF; ejection fraction; peak late diastolic velocity; atrial fibrillation; angiotensin-receptor blocker; advanced echocardiography arm; left ventricular; heart failure; stage A heart failure; beta-blocker; cardiovascular; global longitudinal strain; peak early mitral annular tissue Doppler velocity; angiotensin-converting enzyme inhibitor; diastolic dysfunction; mitral inflow peak early diastolic velocity; usual care arm; hypertension
• ISSN: 1936-878X; 1876-7591; 1876-7591
• DOI: 10.1016/j.jcmg.2016.11.015

The purpose of the study was to evaluate the benefit of care guided by the detection of stage B heart failure (SBHF) using advanced echocardiography for the reduction of new HF in the community. The detection of nonischemic SBHF has been facilitated by advanced echocardiographic imaging modalities. However, improved outcomes have not been proven as they are predicated on benefit of treatment. Between September 13, 2013 and November 6, 2015, 618 asymptomatic community-based patients with HF risks (age 71 ± 5 years) were randomized to care guided by advanced echocardiography (myocardial deformation and detailed diastolic function) versus usual care. Evidence of SBHF led to advice to the patients and their primary physicians to initiate treatment with angiotensin-converting enzyme inhibition and beta-adrenoceptor blockade. The trial followed the PROBE (Prospective Randomized Open Blinded Endpoint) design. Participants were followed for 1 year for the primary composite endpoint of death from cardiovascular causes and new HF. Advanced echocardiography identified 219 as having SBHF and treatment was advised. Over a mean follow-up of 13 ± 6 months, 67 reached the primary endpoint. The incidence rate of HF was no different between the 2 arms (p = 0.47), likely because only 43% initiated therapy, and only 9% achieved target dose. Among subjects needing therapy on the basis of imaging and adherence to therapy, imaging-guided care showed a 77% lower hazard for the primary outcome (p = 0.04). The detection of SBHF from strain and diastolic function evaluation was associated with a higher incidence of incidence HF and death. The efficacy of pharmacological intervention with angiotensin-converting enzyme inhibition and beta-adrenoceptor blockade is limited by its uptake, and alternative strategies should be considered. (Tasmanian Study of Echocardiographic Detection of Left Ventricular Dysfunction [TAS-ELF]; ACTRN12614000080628) [Display omitted]