Biomarkers and Future Strategies in Heart Failure
Sheryl Chow, PharmD, BCPS; Akshay Desai, MD; Peter L. Salgo, MD; and Scott Solomon, MD, provide an update on the potential role of biomarkers in heart failure management and share their thoughts on heart failure prevention strategies.
Peter L. Salgo, MD: We’ve got guidelines. You said there was a partial update to the guidelines, but there’s going to be a full guideline update sometime this year. Is that right?
Sheryl Chow, PharmD, BCPS: That’s correct.
Peter L. Salgo, MD: When do we expect it?
Sheryl Chow, PharmD, BCPS: I would hope in the next several months. Right now, it’s under the peer review process. That can take some time, depending on the number of peer reviewers and the number of comments that they have. Currently, what should be out in the next month or two, is the American Heart Association Scientific Statement for Biomarkers in Heart Failure.
Peter L. Salgo, MD: What does that mean?
Sheryl Chow, PharmD, BCPS: Basically, it’s a focus on the role of biomarkers in the assessment, the prevention, and the management of heart failure. So, it encompasses quite a bit. It’s also going to have some recommendations there, and some considerations, which are going to be matched with what the full guidelines will provide.
Peter L. Salgo, MD: But I just heard that some of the medications, the ARNIs (angiotensin receptor neprilysin inhibitors), that we’re prescribing are going to mess up the biomarkers.
Sheryl Chow, PharmD, BCPS: Yes. My perspective might be a little different from Scott’s, where I don’t believe you should necessarily switch. If you’re on an ARNI and you’re in a hospital that looks at BNP (B-type natriuretic peptide), what do we know about BNP? Well, we know that at 1 month, you might get a bump of 20% off that BNP. That’s showing efficacy, so I think, in some ways, it’s more valuable. At 1 month, over the 8-month period, you’re going to see a drop. So, why not use that, a new measurement, at the 1-month period, as a new baseline and then follow it out from there?
Peter L. Salgo, MD: You’re saying that you start the ARNIs, you see a spike, and as the ARNIs become effective and the heart failure gets better, they go down because the heart failure is improving. Is that what you’re saying?
Sheryl Chow, PharmD, BCPS: Correct. At that point, it would be a measurement of improvement of heart failure. You’ve created a new baseline, so that’s one way to try to adjust for using BNP in your institution.
Scott Solomon, MD: Sheryl’s right in that BNP does eventually go down if heart failure gets better, but it’s going to be very confusing, I think, for practitioners. The real question is, how often should we be using these guidelines, these biomarkers, anyway? Should we be following them? Should we use them to decide what patients to give the drugs to? If they don’t go down, do we stop giving the patients drugs? I think there is a lot of questions here that we haven’t yet answered. I certainly don’t know what the guidelines are going to say about this, but I think we have to be very careful—to look at biomarkers alone, without paying attention to all the other things that we’ve been talking about.
Peter L. Salgo, MD: What I heard was the biomarkers can often help break a tie or tip you one way or the other. But more often than not, they’re not going to make the diagnosis for you—the diagnosis made by patient history, a physical exam, an echocardiogram, or whatever other markers you’ve got. So, it’s fascinating. You’re saying that the baseline is interesting. It may not be the “be all and end all.” Is that what you’re saying?
Scott Solomon, MD: Yes, absolutely.
Peter L. Salgo, MD: Looking into the future, there are other models, other programs, that are being looked at to improve heart failure prevention. Heart failure prevention, as far as I know in the traditional model, is, “Eat better, exercise better, pick your parents better, so that your LDLs (low-density lipoproteins) are okay” or “Get them down.” What else is there?
Akshay Desai, MD: Well, I think there’s 2 kinds of prevention. There’s primary prevention, which is what we were talking about before, where you prevent the first episode of heart failure from ever happening. And that’s hypertension control and coronary disease prevention. And then, there’s secondary prevention. You’ve had heart failure, and now you don’t want to have it again. You don’t want to end up back in the hospital. There are a lot of strategies which fit broadly under the rubric of heart failure disease management, and those are the longitudinal programs, heavily nurse- and pharmacist-driven, that are regular surveillance of heart failure patients to reemphasize the educational messages, the self-management messages, and the medication adherence messages that we started in the hospital.
Peter L. Salgo, MD: So this is, again, as we were talking about before, getting them in the system, making sure the system doesn’t forget about them, and bringing them back in to be sure there’s compliance going on.
Akshay Desai, MD: Yes, it’s not a one-off.
Peter L. Salgo, MD: How does that impact readmissions reduction? Or is that a part-and-parcel of the same thing?
Akshay Desai, MD: Well, I think within that scope, there are a lot of different strategies that have been employed. One of them is regular inpatient clinic follow-up, but there are other strategies, including remote monitoring. So, although telemonitoring of weights and vital signs hasn’t routinely shown impact on readmissions prevention, it is an adjunct to care and a lot of programs do it.
There are other novel monitoring strategies that are under exploration, including serial measurement of natriuretic peptides, and other measures of impedance, or filling pressures, even. And then there are strategies for what to do when the patient gets in trouble. So, if the patient is symptomatic, 1 strategy is to send them to the emergency department, in which case they usually get admitted. But another strategy is to try to treat them in the outpatient setting with intravenous diuretics in a clinic or an observation unit, and those strategies are drawing attention. With some more innovative visiting nurse agencies, we can now deliver diuretics in the patient’s home environment, and that’s a way of preventing them from having to come to the hospital.