Why is HFpEF often missed or diagnosed late?
Thank you so much. And you know, until last year, we really didn’t have definitive therapies for heart failure with preserved ejection fraction. So I think as a community, we’re only now building programs to really identify heart failure with preserved ejection fraction at an earlier time point. This population too is older, has multiple comorbidities, has frailty, and so many of the symptoms that may be truly related to heart failure may be misattributed to other comorbidities,and may be put off as perhaps just a symptom of aging. I think that re-education process is one that’s gonna be so critical to move the diagnosis to an earlier time point in the trajectory of HFpEF.
What do you think is the role of NT-proBNP in the diagnosis of HFpEF?
Yeah, so NT-proBNP is very, very interesting in terms of its role in HFpEF. For many reasons, NT-proBNP levels are affected in the context of HFpEF, primarily because left ventricular hypertrophy, that’s common in HFpEF may limit diastolic wall stress, so may limit the impetus for natriuretic peptide release. Furthermore, obesity of the chest wall and pericardial constraint may also limit NT-proBNP release as well. In addition, HFpEF, as we mentioned, has multiple intersecting comorbidities that may modulate the levels of natriuretic peptides, either the production or clearance of natriuretic peptides, including age, sex, race, obesity, kidney function, atrial fibrillation status, all critically important determinants of HFpEF status. And so many in the community have found it challenging, I think, to interpret the levels of NT-proBNP in the context of HFpEF, given the complexity of these issues.
That said, I would argue that NT-proBNP still has a critical role, even in the screening and diagnosis of HFpEF, despite those complexities. And while the overall distribution of NT-proBNP levels may be shifted downwards, may be lower than for, for instance, patients with heart failure with reduced ejection fraction, we can still interpret those levels and they may be elevated for that individual patient. So I think identifying what is normal for an individual patient with HFpEF is something that we really should start to strive for in current care.
What would be necessary to help facilitate the interpretation of NT-proBNP results in special cohorts of patients with HFpEF?
Now that we have therapies to implement and care of HFpEF, I think the diagnosis is going to be of paramount interest. And as we democratize the field and actually in terms of identification, even in primary care, endocrinology, nephrology practices, I think that education will be very, very important. I think the cardiology community has been using natriuretic peptides in various contexts, so have grasped, some, some understanding of that variability.
That said, I think there are ways that we can make things easier for clinicians to interpret these data. We know in adjacent fields, like in kidney disease, there are estimated values to… using measured parameters such as serum creatinine to estimate glomerular filtration that adjust or accounts for some of the variability in factors such as age, sex, and race.
Similarly, I think we can do, we can strive and perhaps move towards similar calculator or more precise approaches to understand what is normal for an individual participant. And can we actually calibrate it based on the various factors that intersect in that individual patient with HFpEF.
How can we further improve the diagnosis of heart failure with preserved ejection fraction in the future, now that new treatment options have proven effective?
So I think that until now, HFpEF is a condition that all of us saw in practice,but it was something that we largely, perhaps side stepped because it’s a challenging conversation to tell a patient that you have heart failure. They will all often ask, “Well, then what next? And what should we do, to help prevent progression?” Now that we have tools to help us, I think there will be greater interest in the community. I think we need to band together as a community to push forth educational efforts, not only in terms of what is HFpEF in terms of the diagnostic criteria, but how, what are the clues that can put us to a path of screening. And so there are really quite helpful and useful diagnostic scores, such as the H2FPEF score, that integrates readily available parameters, that are including echocardiographic parameters that may increase the probability of HFpEF for an individual patient. These types of screening tools may then be positioned alongside natriuretic peptides to really identify those at greatest risk for having HFpEF, so maybe flagged, for instance, in a health system as potential HFpEF patients.
What are your hopes for cardiovascular care in the future?
Oh, it’s… that again is a million dollar question. I think the, you know, to date we have seen, of course, really large implementation gaps and tremendous inertia not only in the treatment, but also the screening and diagnosis of chronic illness in cardiovascular disease. And so in changing this, I think we have to really move from implementation being something that has been locally driven and locally rooted to something that is more systematic at really a global scale, to be able to implement programs that can efficiently screen, diagnose and manage patients with diseases like heart failure. Because these conditions are now becoming to a point that they’re treatable. We’ve always, you know, considered in terms of adjacent fields like cancer care, that striving for a cure. And now we have such effective therapies that we can actually improve the longevity as well as the health related quality of life of patients. And so it’s upon us, I think, to build those programs to effectively and in a structured manner, screen diagnose and treat patients.
