A team from UCD and St Vincent’s Hospital has produced award-winning research which has set a template for major improvements in the diagnosis and management of heart failure.

The title of the study was ‘Natriuretic peptide-based screening and collaborative care for heart failure – the STOP-HF randomised trial’.’

This trial first won a place in the late breaking clinical trials session at the American College of Cardiology Conference and it was then published in JAMA. It then won the research paper of the year award at the most recent RCGP primary care conference in Liverpool, where the award was accepted by Dr Joe Gallagher on behalf of the research team.

The team was led by Prof Ken McDonald and Dr Mark Ledwidge.

According to Mr Gallagher: “one of the ideas behind the research was to personalise heart failure prevention, and to aim for earlier intervention in patients at risk of HF. 

“Our standard risk factors, like HbA1c levels, blood pressure etc, are based on population-based values,” he added. 

“Obviously, that type of risk factor needs to be managed, but the idea behind our research was to effectively use the blood natriuretic peptide (BNP) test, checking for levels of the hormone produced by the individual’s response to stress on their cardiovascular system. If BNP is elevated it is the body telling you the heart is under stress and more targeted care is needed. So this is very personalised and targeted testing treatment,” explained Mr Gallagher.

The study involved just over 1,300 patients from 39 primary care centres, mostly around the east coast of Ireland. Patients were randomly assigned to receive usual primary care (n = 677) or screening with BNP testing (n = 697). 

“All participating patients, said Dr Gallagher, “had one or more risk factors for heart failure. Those found to have an elevated level of BNP – a key signal for HF – received more intensive investigation and care. They had echocardiograms, cardiovascular nurse coaching and a specialist review. The management of these patients was provided jointly by GPs and consultants.

It was found that this approach led to a major reduction in heart failure and ventricular dysfunction, which was the primary outcome of the study, but interestingly, there was a reduction in other cardiovascular events as well.”

As well as reducing repeated heart failure and hospital admissions for patients at high risk of cardiovascular disease, the new management approach also reduced new onset heart failure and also led to a 40% reduction in hospital admissions for other major cardiovascular episodes such as MI, stroke and AF.

Heart failure occurred in 14 (2.1%) of 677 control-group patients and seven (1.0%) of 697 intervention-group patients. The incidence rates of emergency hospitalisation for major cardiovascular events were 40.4 per 1,000 patient-years in the control group versus 22.3 per 1,000 patient-years in the intervention group .

The researchers concluded that among patients at risk of heart failure, BNP-based screening and collaborative care reduced the combined rates of LV systolic dysfunction, diastolic dysfunction and heart failure.

According to Dr Gallagher: “The management programme initiated in STOP-HF allows us to focus care on this particularly high-risk group, while looking after the lower-risk patients as well.

“The BNP test itself costs around e20, so it’s relatively expensive to carry out but it has now shown to be cost-effective in terms of saving money on treating patients for heart failure and other cardiovascular events.”

Dr Gallagher said the trial focused on heart failure prevention and then also stressed the benefit of focusing care on those who are most at risk, using biomarkers to identify high-risk patients.

“The aim was to develop a sustainable disease prevention and management programme from the knowledge gained from the trial.

“We can’t manage adequately the numbers of patients coming through the system. So by focusing intensive management on those most at risk we have a more effective system.

“Also, the study has highlighted the benefits of collaborative care between hospitals and primary care.”

Because therapies are improving all the time, says Dr Gallagher, heart failure is now essentially becoming a chronic condition. A recent study at the heart failure clinic in St Michael’s Hospital in Dun Laoghaire showed that the five-year survival rate was now 65%. This was one of the best results demonstrated internationally. In many other countries it is only around 50%.

Dr Gallagher said “the reason behind this result include the fact that St Michael’s has a rapid access clinic for heart failure patients. There is also a major focus there on self-care, working with the families of patients. This type of approach really seems to make an impact on preventing patients from deteriorating.”

The STOP-HF programme is also being studied in the Midlands Diabetes Scheme, a primary care-based structured scheme run by GP Dr Velma Harkins. The Dun Laoghaire service is now providing the heart failure prevention programme at six midlands practices to determine the best way to run the service in the community.