Screening for left ventricular dysfunction in the community: role of hand held echocardiography and brain natriuretic peptides

Determining the role of NT-proBNP levels in diabetic patients with heart failure: A study from North India

BACKGROUND

Diabetic patients are at higher risk of cardiovascular morbidity and mortality. NT-proBNP levels measurements are useful for the assessment of risk in heart failure patients in emergency condition and give the faster result. Further, it also offers lower cost and unnecessary hospitalization and follow-up cost. The studies have shown that NT-proBNP levels are a direct predictor of outcome risk in diabetic patients with heart failure. The objective of this research was to study the role of NT-proBNP levels to determine the severity of heart failure in diabetic patients.

MATERIALS AND METHODS

In this study 150 patients diagnosed with symptomatic heart failure admitted to the emergency department of a tertiary care center from January 2021 to January 2022 have been included in Saraswati Institute Of Medical Sciences, Hapur, India. N-terminal pro-B-type natriuretic peptide (NT-Pro-BNP) levels were measured using an automated analyzer ranging between 60 and 3000 pg/ml. According to the European society of cardiology (ESC) guidelines, it has been defined as NT-Pro-BNP level above 125 pg/ml indicates a high possibility of heart failure and NT-Pro-BNP level below 125 pg/ml excludes the high possibility of heart failure. All the patients underwent an echocardiographic study and ejection fraction was calculated and recorded.

RESULTS

In diabetic patients ejection fraction was significantly lower in diabetic patients: 47.15 ± 8.75% vs. 43.24 ± 9.54%, P = 0.002). We have observed statistically significant lower HDL values (40.10 ± vs. 35.94 mg/dL, P = 0.0004), however, significant higher triglycerides values were found (101.43 ± 41.7 mg/dL vs. 151.37 ± 78.85, P = 0.001). No significant difference was observed in LDL level (97.8 ± 31.23 vs. 92.35 ± 314.2, P ≥ 0.05) and total cholesterol level (161.49 ± 41.38 vs. 159.97 ± 41.12, P ≥ 0.05).

CONCLUSION

We concluded that the measurement of NT-proBNP in heart failure and diabetic patients could be an economic marker for the evaluation of morbidity and mortality, facilitating better management and follow-up.

Evidence for models of diagnostic service provision in the community: literature mapping exercise and focused rapid reviews

Background

Current NHS policy favours the expansion of diagnostic testing services in community and primary care settings.

Objectives

Our objectives were to identify current models of community diagnostic services in the UK and internationally and to assess the evidence for quality, safety and clinical effectiveness of such services. We were also interested in whether or not there is any evidence to support a broader range of diagnostic tests being provided in the community.

Review methods

We performed an initial broad literature mapping exercise to assess the quantity and nature of the published research evidence. The results were used to inform selection of three areas for investigation in more detail. We chose to perform focused reviews on logistics of diagnostic modalities in primary care (because the relevant issues differ widely between different types of test); diagnostic ultrasound (a key diagnostic technology affected by developments in equipment); and a diagnostic pathway (assessment of breathlessness) typically delivered wholly or partly in primary care/community settings. Databases and other sources searched, and search dates, were decided individually for each review. Quantitative and qualitative systematic reviews and primary studies of any design were eligible for inclusion.

Results

We identified seven main models of service that are delivered in primary care/community settings and in most cases with the possible involvement of community/primary care staff. Not all of these models are relevant to all types of diagnostic test. Overall, the evidence base for community- and primary care-based diagnostic services was limited, with very few controlled studies comparing different models of service. We found evidence from different settings that these services can reduce referrals to secondary care and allow more patients to be managed in primary care, but the quality of the research was generally poor. Evidence on the quality (including diagnostic accuracy and appropriateness of test ordering) and safety of such services was mixed.

Conclusions

In the absence of clear evidence of superior clinical effectiveness and cost-effectiveness, the expansion of community-based services appears to be driven by other factors. These include policies to encourage moving services out of hospitals; the promise of reduced waiting times for diagnosis; the availability of a wider range of suitable tests and/or cheaper, more user-friendly equipment; and the ability of commercial providers to bid for NHS contracts. However, service development also faces a number of barriers, including issues related to staffing, training, governance and quality control.

Limitations

We have not attempted to cover all types of diagnostic technology in equal depth. Time and staff resources constrained our ability to carry out review processes in duplicate. Research in this field is limited by the difficulty of obtaining, from publicly available sources, up-to-date information about what models of service are commissioned, where and from which providers.

Future work

There is a need for research to compare the outcomes of different service models using robust study designs. Comparisons of ‘true’ community-based services with secondary care-based open-access services and rapid access clinics would be particularly valuable. There are specific needs for economic evaluations and for studies that incorporate effects on the wider health system. There appears to be no easy way of identifying what services are being commissioned from whom and keeping up with local evaluations of new services, suggesting a need to improve the availability of information in this area.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

The feasibility, diagnostic yield, and learning curve of portable echocardiography for out-of-hospital cardiovascular disease screening

BACKGROUND

The reduction in the size of full-capability echocardiographic machines facilitates "out-of-hospital" transthoracic echocardiography (TTE). Data documenting the feasibility, yield, and logistical considerations of out-of-hospital TTE for preparticipation evaluation of athletes are sparse.

METHODS

A multiyear study was conducted to examine the role of 12-lead electrocardiography for athlete screening in which TTE was used to document or exclude underlying structural heart disease. Using a commercially available portable transthoracic echocardiographic system, the rate of technically adequate imaging, diagnostic yield, and the time required for the completion of TTE (including setup, performance, and interpretation) were examined. TTE was performed in university medical offices and at "out-of-office" athletic facilities. Measurements were recorded during each year of the study to determine the impact of targeted attempts to improve efficiency.

RESULTS

Four hundred sixty-seven of 510 participants had transthoracic echocardiographic images that were technically adequate for complete interpretation (imaging success rate, 92%). Echocardiographic evidence of physiologic, exercise-induced cardiac remodeling was observed in 110 of 510 (22%). Cardiac abnormalities with relevance to sports participation risk were detected in 11 of 508 participants (2.2%). Over 3 years, the average time for the completion of TTE (including setup, imaging, and interpretation) decreased (year 1, 17.4 ± 3 min; year 2, 14.0 ± 2.1 min; year 3, 11.0 ± 1.8 min; P < .001). This was driven by a significant decrease in the time required for TTE at out-of-office athletic facilities.

CONCLUSIONS

Community-based TTE in athletes is feasible and is associated with a high rate of technically adequate imaging. Importantly, there appears to be a significant learning curve associated with out-of-hospital TTE.

The Relationship between Serum NT- Pro-BNP Levels and Prognosis in Patients with Systolic Heart Failure

INTRODUCTION

Most studies reported using N-terminal pro-brain natriuretic peptide (NT-proBNP) in diagnosis of heart failure but there is controversy about use of these tests in determining prognosis and classification of severity of heart failure. The objective of this study was to determine the value of plasma NT-proBNP levels assessment in evaluation of mortality and morbidity of patients with systolic left ventricular dysfunction.

METHODS

A cohort study was performed in 150 patients with heart failure since September 2009 until February 2010. The patients were followed for 6 months to assess their prognosis. Patients were divided into two good and bad prognosis groups according to severity of heart failure in New York Heart Association (NYHA) class and frequency of hospital admission and mortality due to cardiac causes. Patients with good prognosis had ≥1 admission or no mortality or NYHA class ≥2 and patients that had one of this criteria considered as bad prognosis groups. Pro-BNP levels were measured at baseline and left ventricular ejection fraction (LVEF) was estimated with echocardiography. Data was analyzed with using Chi-square, t-test, ANOVA, Kruskal-Wallis tests.

RESULTS

In patients with heart failure that enrolled in this clinical study, ten patients were lost during follow-up. The mean of NT-proBNP is significantly correlated with ejection fraction (p=0.003) and NYHA class (p<0.001). In our study among 140 patients who were follow-up for 6 months, 11(9.7%) of individuals died with mean NT-proBNP of 8994.8±8375 pg/ml, in survived patients mean NT-proBNP was 3756.8±5645.6 pg/ml that was statistically significant (P=0.02). Mean NT-proBNP in the group with good prognosis was 2723.8±4845.2 pg/ml and in the group with bad prognosis was 5420.3±6681 pg/ml, difference was statistically significant (P=0.0001).

CONCLUSION

Our study in consistent with other studies confirms that NT-proBNP is significantly correlated with mortality and morbidity. This could be predicting adverse out come and stratification in patients with heart failure. It is recommended that more research be performed in Iran.

Agreement between community echocardiography and hospital echocardiography in patients suspected of having left ventricular systolic dysfunction

BACKGROUND

Smaller echocardiography machines, when used in hospitals, are accurate for detecting left ventricular dysfunction and valvular disease. This paper assessed the detection of left ventricular dysfunction and of valvular disease in the community setting by a smaller machine.

AIMS

To measure the agreement in patients with suspected heart failure between community echocardiography and traditional echocardiography in the hospital in detecting left ventricular dysfunction and significant valve disease.

METHODS

Suspected heart failure patients were referred to one of the authors (SJ) for community echocardiography using a Siemens Cypress machine. The patients had a second echocardiogram in the hospital by another sonographer who was blinded to the results of the first echocardiogram. The reports of the two sonographers were assessed for agreement using kappa statistics.

RESULTS

458 patients had a community echocardiogram and 136 agreed to a second echocardiogram in the hospital. There was excellent agreement, kappa = 0.87 (0.06 SE), for the detection of left ventricular dysfunction between community echocardiography and the hospital machine. The detection of significant valvular disease was good, kappa = 0.75 (0.06) between the community echocardiogram and hospital machines.

CONCLUSIONS

In suspected heart failure patients, community echocardiography gives comparable results to traditional hospital echocardiography for left ventricular dysfunction detection and for significant valvular disease detection.

What is the most cost-effective strategy to screen for left ventricular systolic dysfunction: natriuretic peptides, the electrocardiogram, hand-held echocardiography, traditional echocardiography, or their combination?

AIMS

To assess the screening characteristics and cost-effectiveness of screening for left ventricular systolic dysfunction (LVSD) in community subjects.

METHODS AND RESULTS

A total of 1392 members of the general public and 928 higher risk subjects were randomly selected from seven community practices. Attending subjects underwent an ECG, N-terminal pro-brain natriuretic peptide (NTproBNP) serum levels, and traditional echocardiography (TE). A total of 533 consecutive subjects underwent hand-held echocardiography (HE). The screening characteristics and cost-effectiveness (cost per case of LVSD diagnosed) of eight strategies to predict LVSD (LVSD <45% on TE) were compared. A total of 1205 subjects attended. Ninety six per cent of subjects with LVSD in the general population had identifiable risk factors. All screening strategies gave excellent negative predictive value. Screening high-risk subjects was most cost-effective, screening low-risk subjects least cost-effective. TE screening was the least cost-effective strategy. NTproBNP screening gave similar cost savings to ECG screening; HE screening greater cost-savings, and HE screening following NTproBNP or ECG pre-screening the greatest cost-savings, costing approximately 650 Euros per case of LVSD diagnosed in high-risk subjects (63% cost-savings vs.TE).

CONCLUSION

Thus several different modalities allow cost-effective community-based screening for LVSD, especially in high-risk subjects. Such programmes would be cost-effective and miss few cases of LVSD in the community.

Ethnic differences in the prevalence and aetiology of left ventricular systolic dysfunction in the community: the Harrow heart failure watch

OBJECTIVE

To assess ethnic differences in the prevalence and aetiology of left ventricular systolic dysfunction (LVSD) in the community.

DESIGN

Community cohort study. All patients underwent echocardiography and those found to have LVSD underwent myocardial perfusion imaging with or without coronary angiography to diagnose underlying coronary artery disease (CAD).

SETTING

Seven representative general practices in Harrow, UK, a community hospital, and a local district general hospital.

PATIENTS

1392 patients >or= 45 years old randomly selected from the computer records of seven general practices.

MAIN OUTCOME MEASURES

The prevalence and aetiology of LVSD in the community, assessing differences between white and non-white populations, and the proportion of patients with LVSD with undiagnosed CAD.

RESULTS

734 patients (53%) attended, 518 (71%) white and 216 (29%) non-white, the majority South Asian. Thirty nine patients (5.5%) had probable LVSD and 25 (3.5%) definite LVSD. No significant differences in prevalence were seen with ethnicity. CAD underlay most cases of LVSD. Non-white patients had a higher prevalence of CAD as the underlying aetiology of significant LVSD than white patients (100% v 56%, p = 0.04) and a trend towards less alcoholic cardiomyopathy. 8% of patients with LVSD had undiagnosed CAD.

CONCLUSIONS

LVSD is common. White and non-white patients have a similar overall prevalence of LVSD. Non-white patients, the majority South Asians in this study, have a higher prevalence of CAD as the underlying cause for LVSD than white patients. CAD underlies most cases of LVSD in the community, although it may be undiagnosed unless formally assessed.