STOP-HF Investigators

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The Saint Vincents Screening To Prevent Heart
Failure (STOP-HF) Study A Multicentre,
Prospective, Randomised, Controlled Trial of
Natriuretic Peptide Based Screening And
Collaborative Care To Reduce The Prevalence of
Left Ventricular Dysfunction and Heart Failure
STOP-HF Investigators St. Vincents / St.
Michaels Hospitals and Collaborative GP
Group Dublin, Ireland
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STOP-HF Background

• Prevention of heart failure is a Holy Grail of
  cardiovascular care
• Present approaches are suboptimal
• Risk differentiation based on clinical criteria
  may be limited
• Biomarkers may help to focus care to where it is
  most needed

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Individualizing Risk with NP
Framingham Cohort, Wang et al. NEJM 2004 NP
predicts HF and CV Risk

• Peptide secreted in response to
• Pressure / Volume Overload
• Ischemia
• Fibro-inflammation
• Adds to routine risk prediction
• NP reflects established CV insult rather than
  risk of CV damage

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STOP-HF Hypothesis

• NP-driven screening and targeted collaborative
  care in the general at-risk population will
  decrease the prevalence of LVD and HF
• 39 collaborating primary care practices,
  intervention provided in a single referral center

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STOP-HF Inclusion / Exclusion

• Excluded
• Known LVSD or HF
• Life-threatening illness
• Refusal / inability to give informed consent

• Entry Criteria (gt 40yrs) with
• Hypertension
• Hyperlipidemia
• Diabetes
• Vascular disease
• Arrhythmia
• Obesity

• Primary End Point
• Prevalence of heart failure (hospitalized) and
  asymptomatic left ventricular dysfunction
• Systolic Dysfunction LVEF lt 50
• Diastolic Dysfunction E / e prime gt 15
• Secondary End Point
• Hospitalization for Cardiovascular Events (Time
  to event and Event rate)
• Heart Failure, Arrhythmia, Myocardial Infarction,
  Unstable angina, CVA, TIA, Peripheral Thrombosis,
  PE

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Study Flow
n3,123
n1,374
n677
n697
Lost to follow up n69 Withdrew consent
n132 Death n37
Lost to follow up n70 Withdrew consent
n92 Death n35
Intention to treat analysis
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STOP-HF Intervention

• Routine PCP care
• Annual BNP not available to clinicians
• At least annual review by PCP
• Cardiology review only if requested by PCP

• NP-directed care
• In addition to routine PCP care
• Annual BNP in all
• If BNP gt50pg/ml at any time
• Shared-care
• Cardiology review
• Echo-Doppler
• Other CV investigations
• CV nurse coaching
• Regular Cardiology follow-up

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Demographics
9
Demographics
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Primary Endpoint HF and LVD
OR 0.46 0.27, 0.77, p0.003
N44
OR 0.59 0.38, 0.90, p0.01
N25
N59
N39
Any BNP gt 50 pg/ml
Total Population
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Endpoint Time to First MACE
OR 0.67 0.46,0.98 p0.04
OR 0.70 0.47,1.03 p0.07
Intervention Control
Any BNP gt 50 pg/ml
Total Population
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Endpoint MACE Event Rate
Event Rate OR 0.54 p0.001 vs. Control
N71 (10.5)
N51 (7.3)
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Therapies and Risk Factors

• BP significantly reduced within both groups
  (plt0.001) from baseline
• Increased use of RAAS modifying therapies in
  intervention group
• Trend to lower HR (p0.09) and LDL-C (p0.06) in
  high BNP subsets
• 75 of primary end-point in control group had BNP
  gt 50pg/mL

SBP (mmHg) -9.2 -9.9
HR (bpm) 0.0 -1.2
LDL-C (mg/dL) 0.0 -2.9
P0.02
Baseline ()
42 43
52 53
25 27
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Limitations

• One geographical region in one health system
• Self-selected PCP
• Unblinded study
• Multifactorial intervention
• Only included documented hospitalization events
  in MACE

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STOP-HF Conclusion

• Natriuretic peptide-based screening and
  collaborative care targeted 4 in 10 at-risk
  patients
• Reduced the rates of left ventricular
  dysfunction, heart failure, and emergency
  hospitalizations for major cardiovascular events.
  

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STOP-HF Investigators
Principal Investigators Kenneth McDonald,
MD Mark Ledwidge, PhD Co-investigators Joseph
Gallagher, MB Carmel Conlon, PhD Elaine Tallon,
PGDip Eoin O Connell, MSc  Ian Dawkins, PhD
Chris Watson, PhD Rory O Hanlon, MD Margaret
Bermingham,BPharm Anil Patle, MBA Mallikarjuna R
Badabhagni, BSE Gillian Murtagh, MD Victor Voon,
MB Laura McDonald Brian Maurer, MD
Funding Sources Heartbeat Trust Registered
Charity CHY 15398 European Commission
Framework Programme 7 Grant 261409
MEDIA Department of Health of Irish
Government Health Services Executive St
Vincents University Healthcare Group