Early Intervention in Heart Disease

Dr Joe Gallagher

Early detection of heart problems in patients, followed by collaborative support from GPs and other medical teams, can reduce heart failure and stroke, according to the ground breaking study winning the RCGP 18 annual Research Paper of the Year Award.

The work, showcased during a plenary session at the RCGP annual conference, demonstrated that early detection of heart disease supported by collaborative treatment reduced new onset heart failure and heart dysfunction by a staggering 45% and led to a reduction of the incidence of heart attack and stroke by 40%. Heart dysfunction was identified by detecting elevated natriuretic peptide, proteins which are released when the heart is under stress or strain even before a clinical event occurs. Patients who had elevated levels of natriuretic peptide received a tailored care package of an echocardiogram (ultrasound of the heart), cardiovascular nurse lifestyle advice, and cardiologist review with on-going collaborative care with their GP.

Professor Chris Salisbury, who chairs the Research Paper of the Year, was asked why the paper won the award:

"The researchers used natriuretic peptide to identify asymptomatic patients at high risk of heart failure, followed by collaborative care to optimise their treatment. The intervention reduced left ventricular dysfunction, symptomatic heart failure and hospital admissions. This approach of using screening and risk-prediction tools to identify high risk patients who are then treated intensively and collaboratively by primary and secondary care is very applicable to a range of other long-term conditions."

Dr Joe Gallagher, GP and one of the research paper's authors, summarises the work below highlighting its importance to general practice:

A brief description of the work

The STOP-HF study used B-type Natriuretic Peptide (BNP) to screen patients at risk of heart failure and other cardiovascular diseases to help identify those at highest risk. Care was then targeted at this group resulting in a significant reduction in heart failure and left ventricular dysfunction, and also in admissions for major adverse cardiovascular events.

Why this work is important

The increasing prevalence of heart failure and other cardiovascular diseases remains a major public health concern. This may be explained partly by the uniform direction of resources to a population containing predominantly lower risk patients. Also the lack of personalisation of risk beyond that calculated from standard risk factors hampers targeting of care and resources due to the large populations involved.

Why natriuretic peptides are important

Natriuretic peptides, specifically BNP and NTproBNP, have been shown to identify patients at highest risk of cardiovascular events; some studies have demonstrated that these can be superior to conventional risk indicators which may simply reflect a potential for cardiovascular insult.

The approach to work

The ST Vincent's Screening to Prevent Heart Failure (STOP-HF) study was designed as a pragmatic, prospective randomised controlled trail in a community population. By having broad inclusion criteria and few exclusion criteria we sought to make the population applicable to everyday clinical practice and test the hypothesis that BNP-based screening and intervention would target management to patients at highest risk of heart failure and cardiovascular disease. Our aim was to provide an approach to the prevention of heart failure and cardiovascular disease that would be superior to standard care.

39 GP practices participated in the study. A wide range of patients with cardiovascular risk factors or cardiovascular disease were eligible to participate. In the intervention group, all patients with a BNP value of 50 pg/mL or higher were referred to the specialist cardiovascular service. Patients underwent a multidimensional intervention that included echocardiography, review by a cardiologist, followed by further coaching by a specialist nurse; the nurse highlighted the importance of adherence to medication and healthy lifestyle behaviours and emphasised the patients individual risk status. Patients with BNP values less than 50 pg/mL received the same care as provided in the control group (usual GP care), but with disclosure of BNP values to patients and GPs.

Improving patient outcomes

We demonstrated that there was a statistically significant reduction in both left ventricular dysfunction and in the incidence of emergency hospitalisation for major cardiovascular events.

The improvement in the clinical outcome for patients was associated with increased use of ACE inhibitors and angiotension receptor blockers in patients with elevated BNP levels. These agents have been shown to be effective in reducing fibro-inflammation which is associated with an elevated natriuretic peptide level. There was also increased use of cardiovascular diagnostics.

Our work suggests that implementing a targeted strategy for cardiovascular disease prevention using natriuretic peptides to detect problems and supporting this collaborative care in a community population is an effective model of care. Our work provides a model that could be implemented to identify and treat patients most at risk in the burgeoning epidemic of cardiovascular disease.

To read the winning research paper:

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 randomised trail. JAMA. 2013. 210(1):66-74. DOI: 10.1001/jama.2013.7588.

The other winning category awards (these will be featured in future RCGP Clinical News editions) were:

Category 1 Cancer
Murchie P, Raja EA, Lee AJ, Campbell NC. Mortality and morbidity after initial diagnostic excision biopsy of cutaneous melanoma in primary versus secondary care. Br J Gen Pract. 2013. 63(613):e563-72. DOI: 10.3399/bjgp13X670697.

Category 3 Reproduction, Children, Genetics and Haematology
Dommett RM, Redaniel T, Stevens MC, Martin RM, Hamilton W. Risk of childhood cancer with symptoms in primary care: a population-based case-control study. Br J Gen Pract. 2013. 63(606):e22-9. DOI: 10.3399/bjgp13X660742.

Category 4 Neurology, Mental Health and Dementia
Matthews FE, Arthur A, Barnes LE, Bond J, Jagger C, Robinson L, Brayne C; Medical Research Council Cognitive Function and Ageing Collaboration. A two-decade comparison of prevalence of dementia in individuals aged 65 years and older from three geographical areas of England: results of the Cognitive Function and Ageing Study I and II. Lancet. 2013. 382(9902):1405-12. DOI: 10.1016/S0140-6736(13)61570-6.

Category 5 Primary Care, Public Health, Service Delivery and Musculoskeletal
Kennedy A, Bower P, Reeves D, Blakeman T, Bowen R, Chew-Graham C, Eden M, Fullwood C, Gaffney H, Gardner C, Lee V, Morris R, Protheroe J, Richardson G, Sanders C, Swallow A, Thompson D, Rogers A; Salford National Institute for Health Research Gastrointest Implementation of self management support for long term conditions in routine primary care settings: cluster randomised controlled trial. BMJ. 2013. 346:f2882. DOI: 10.1136/bmj.f2882.

Category 6 Urgent Care, Infections, Respiratory and Gastroenterology
Pinnock H, Hanley J, McCloughan L, Todd A, Krishan A, Lewis S, Stoddart A, van der Pol M, MacNee W, Sheikh A, Pagliari C, McKinstry B. Effectiveness of telemonitoring integrated into existing clinical services on hospital admission for exacerbation of chronic obstructive pulmonary disease: researcher blind, multicentre, randomised controlled trial. BMJ. 2013. 347:f6070. DOI: 10.1136/bmj.f6070.

For further information about the Research Paper of the Year Award please click here.

To read the RCGP press release please click here.

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