Benefit of early initiation of disease-modifying therapy in community-based patients with suspected heart failure

The initiation of heart failure (HF) therapies at the time of detection of an elevated N-terminal pro-B-type natriuretic peptide (NT-proBNP) level in community-based patients with suspected HF may reduce the risk of early adverse outcomes. The aim of this analysis was to estimate the potential benefit of the early initiation of a sodium-glucose cotransporter 2 inhibitor (SGLT2i) and/or mineralocorticoid receptor antagonist (MRA) in patients with suspected HF and a pre-existing non-HF-related indication for treatment.

A cohort study was performed from 1 January 2015 to 31 March 2023 using linked primary and secondary care data from the Clinical Practice Research Datalink (CPRD). Patients without a history of HF and who were not prescribed an SGLT2i or MRA were followed up for 12 months following a community-measured NT-proBNP ≥ 400 pg/mL. The primary outcome was a composite of a HF hospitalization as the first recorded HF diagnostic event or death from any cause in patients without a documented HF diagnosis during follow-up and who did not undergo echocardiography. The effect of the initiation of treatment with an SGLT2i, MRA, or both (effective treatments for HF regardless of ejection fraction) was modelled at the time of NT-proBNP measurement in patients with a pre-existing non-HF-related indication for these drugs (Type 2 diabetes, chronic kidney disease, or resistant hypertension) using treatment effect estimates from meta-analyses of randomized placebo-controlled trials in patients with established HF.

An NT-proBNP ≥ 400 pg/mL was recorded in 74 945, 24 082 (32%) of whom had a HF diagnosis recorded within 12 months, 15 398 (64%) as an outpatient and 8684 (36%) during a HF hospitalization. If both an SGLT2i and MRA were commenced at the measurement of an elevated NT-proBNP in those with a pre-existing non-HF-related indication, we estimated that for every 1000 patients treated, 84 would avoid either a HF hospitalization or death at 12 months, equating to a number needed to treat of 12 (95% confidence interval 11–14).

In community-based patients with suspected HF and elevated NT-proBNP, the early initiation of an SGLT2i and an MRA in patients with a pre-existing non-HF-related indication for treatment may reduce the risk of early adverse outcomes whilst awaiting diagnostic echocardiography. These findings suggest a simple clinical strategy with potentially large public health benefits.