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CREDITS
Physicians
0.25 AMA PRA Category 1 Credit(s) ™
Family Physicians
0.25 Elective credits
Release Date:
Feb. 11, 2012
Expiration Date:
Feb. 11, 2013
Estimated time for completion 15.00 minutes
There is no fee for this activity.
To Receive CME Credit
In order to receive your certificate of participation, you should read the information about this activity, including the disclosure statements, review the entire activity, correctly answer all the questions in the post-test, and complete the evaluation form. You may then follow the directions to print your certificate of participation.
Program Overview
Among the many issues clinicians face today, staying current with advances in medicine is becoming a major challenge. Teaching Brief® articles will allow clinicians to stay up-to-date and assimilate new information into their daily practice. The content of these Teaching Brief® articles has been validated through an independent expert peer review process.
Learning Objectives
Upon successful completion of this educational program, the reader should be able to:
1. Discuss the results of this study
2. Review the relevance and significance of the study in the broader context of clinical care
Disclosures
Robert Jasmer, MD, and Todd Neale, have told that they have no relevant financial relationships or conflicts of interest with commercial interests related directly or indirectly to this educational activity.
The staff of the Perelman School of Medicine at the University of Pennsylvania and the staff of MedPage Today have told that they have no relevant financial relationships with commercial interests related directly or indirectly to this educational activity.
Accreditation
This activity has been plotted and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of the Perelman School of Medicine at the University of Pennsylvania and MedPage Today. The Perelman School of Medicine at the University of Pennsylvania is accredited by the ACCME to provide continuing medical education for physicians.
Designation of Credit
The Perelman School Medicine at the University of Pennsylvania designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Credit for Family Physicians
MedPage Today “News-Based CME” has been reviewed and is acceptable for up to 2098 Elective credits by the American Academy of Family Physicians. AAFP accreditation starts January 1, 2012. Term of approval is for one year from this date. Each article is approved for 0.25 Elective credits. Credit may be claimed for one year from the date of each article.
By Todd Neale, Senior Staff Writer, MedPage Today
Published: February 11, 2012
Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco.
Take Posttest
In older adults, echocardiographic variables and levels of N-terminal pro-B-type natriuretic peptide (NT-proBNP) improved heart failure risk stratification compared with a clinical risk score alone, researchers found.
Adding the echocardiographic score, NT-proBNP levels, or both enhanced risk stratification beyond the clinical risk score alone, as indicated by improved Bayesian information criterion (a measure of model fit) and C index (P0.01 for both), according to Javed Butler, MD, MPH, of Emory University in Atlanta, and colleagues.
In addition, the variables boosted integrated discrimination improvement by 61.7% and net reclassification improvement by 16.3% (P0.01 for both), they said.
Because “there are currently no prevention strategies for individuals at increased heart failure risk, barring treatment of asymptomatic left ventricular dysfunction or individual risk factors, it is hard to translate improvement in heart failure risk classification into actionable items or cost-effectiveness gains at this point,” the researchers wrote in the February issue of JACC: Cardiovascular Imaging.
Although echocardiographic evidence of subclinical changes in cardiac structure and function and elevated NT-proBNP levels have been associated with the development of heart failure in cohort studies, it was not known whether they would add any value in stratifying the risk of heart failure beyond clinical factors.
To find out, Butler and colleagues turned to the Cardiovascular Health Study. The current analysis includes 3,752 Medicare-eligible adults (mean age 72.6) who were free from heart failure at baseline. Most of them were white (86.5%) and female (59.2%).
Based on the validated Health Aging and Body Composition (Health ABC) heart failure risk score, most of the participants (59%) had a low five-year risk of developing heart failure (less than 5%). Another 36% had an intermediate risk (5% to 20%) and 5% had a high risk (greater than 20%).
Through five years of follow up, 8% of the participants had a first hospitalization for heart failure.
After accounting for the clinical risk score, several echocardiographic findings were independently associated with incident heart failure (HRs 1.11 to 2.91, P≤0.001 for all):
- Reduced left ventricular ejection fraction
- Abnormal mitral inflow E/A peak velocity ratio (a measure of diastolic function)
- Enlarged left atrium
- Increased left ventricular mass
These variables were used to make an echocardiographic score.
Elevated levels of NT-proBNP also were independently associated with heart failure risk (HR 1.61 as a continuous variable and HR 2.7 for values greater than 190 pg/mL, P0.001 for both).
Adding both the echocardiographic and NT-proBNP levels improved risk stratification more than either factor alone.
Patients with intermediate risk according to the Health ABC gained the most reclassification benefit from the added factors, whereas high-risk patients had lesser gains. Low-risk patients did not gain anything from the added variables.
“The findings from this study provide a solid platform for further research into the establishment of echocardiography as an essential tool for the ‘superior doctor,’ whose goal is to prevent ‘sickness’ from clinically manifest heart failure,” wrote Walter Abhayaratna, MBBS, DrPH, of Australian National University in Canberra, in an accompanying editorial
“Specifically, randomized clinical trials will be required to assess whether the use of echocardiography in concert with natriuretic peptides can be used to identify patients who are at least intermediate risk for incident heart failure by clinical risk scoring, and would benefit from aggressive risk factor modification and pharmacotherapy with neurohumoral modulators,” he noted.
The study authors acknowledged some limitations, including the use of hospital admissions to determine the incidence of heart failure; ascertainment bias stemming from the possibility that patients are more likely to be admitted if they have echocardiographic findings showing left ventricular systolic dysfunction; and the uncertain applicability of the findings to nonwhite individuals and younger populations.
The study was supported by the National Heart, Lung, and Blood Institute (NHLBI), the National Institute on Aging (NIA), the National Institute of Neurological Disorders and Stroke (NINDS), and the University of Pittsburgh Claude D. Pepper Older Americans Independence Center. This project was also partially funded by an Emory University Heart and Vascular Board grant and a Public Health Service Grant from the Clinical and Translational Science Award program of the National Center for Research Resources.
The study authors reported that they had no conflicts of interest.
Abhayaratna reported that he did not have any conflicts of interest.
Primary source: JACC: Cardiovascular Imaging
Source reference:
Kalogeropoulos A, et al “Echocardiography, natriuretic peptides, and risk for incident heart failure in older adults: the Cardiovascular Health Study” JACC Cardiovasc Imaging 2012; 5: 131-140.
Additional source: JACC: Cardiovascular Imaging
Source reference:
Abhayaratna W “Echocardiography for the ‘superior doctor’: a call to action in the managment of heart failure” JACC Cardiovasc Imaging 2012; 5: 141-143.
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