ICS 2012 Report – Community management of cardiovascular risk in Stage A/B heart failure: Six month follow up of the COMPARE-HF cohort

by Edel O’Connell reporting on the presentation by Dr. Stephen Horgan.

Horgan S, Tallon E, Dawkins I, Conlon C, Watson C, Baugh J,Whyte K, Miwa S, McDonald K, Ledwidge M.  St Vincent’s University Hospital, Dublin.

Targeted community risk factor intervention on a population subset with high-risk Stage A/B heart failure resulted in significant reductions in blood pressure and cholesterol levels.

Up to 6 to 10pc of the population suffer from heart failure over the age of 65 which is a fatal and disabling condition, the incidence increases with age.

The growth of heart failure is as a result of an ageing population, poor cardiovascular risk factor management, rising obesity and increasing numbers of people with diabetes.

Current guidelines by the American Cardiology College and the American Heart Association for heart failure describe Stage A/B heart failure, or pre-heart failure, as predominantly community dwelling warranting careful risk factor management.

Patients in stages A and B do not have heart failure, but have risk factors that predispose them toward the development of heart failure.

According to Dr Stephen Horgan, research fellow at the Conway Institute of UCD the purpose of his study was to evaluate the overall cardiovascular risk score of the population subset with Stage A/B heart failure and to determine if the risk score was altered by community risk factor intervention.

The COMPARE AF community programme with cardiovascular risk evaluation study was a prospective, community- based cardiovascular risk-factor screening programme carried out in GP practices; follow-up was provided by trained cardiovascular nurses.

The pilot study included 50 primary care practices across Dublin and the South East of Leinster.

“The prevalence of symptomatic heart failure driven by cardiovascular risk factors in stage A/ B in the COMPARE HF cohort provides useful data for the evaluation of a community based intervention and cardiovascular risk,” Dr Horgan commented.

The intervention involved cardiovascular nurses assessing the patients’ risk factors giving them advice and then in due course reviewing the patients again.

A total of 4,326 patients were included in the COMPARE HF cohort.

Inclusion criteria involved being over 40 and having risk factors such as hypertension, diabetes obesity or having established coronary artery disease.

The results at baseline showed 68.1pc of the patients had hypertension, 38.6pc were obese and 9.9pc had diabetes, while15.1 pc had a history of coronary artery disease.

There were five groups of medications in every group-the intervention resulted in significant increases in dosage or new prescriptions being issued.

In the anti hypertensive agents the percentages increased by roughly 5pc, while there was quite a significant increase when it came to cholesterol lowering therapy -13pc of patients upped their dose or commenced a new statin.

There were also significant increases among those on anti- coagulants, antiplatelet therapy and oral hypoglycaemic therapy.

The study also showed significant reductions in blood pressure after six months-the percentage of patients with high blood pressure at follow- up were 62.9pc compared to 68.1pc at baseline.

There was also a very significant reduction in total cholesterol, which reduced from 5.15 to 4.77- that’s a reduction of 13pc of patients coming back to normal cholesterol levels.

The study did not impact much on BMI and obesity, current smoking, alcohol intake or level of exercise taken, however.

“Unfortunately, these lifestyle measures were not improved by the intervention,” said Dr Horgan.

“Despite reduction in cholesterol and blood pressure we didn’t find a significant reduction in score risk, which was unusual. I felt the finding was related to reductions in moderate risk offset by increases in those at high-risk,” he commented.

The study showed significant reductions in blood pressure and cholesterol were achieved and driven by intervention and intensification of therapies.

However, the prevalence of overweight and obesity remained unchanged and the intervention had no impact on smoking, alcohol intake or current exercise.

Overall cardiovascular risk profile of stage A/B heart failure remained high and patients in moderate risk groups score risk was offset by deteriorations in high risk groups.

“More intensive cardiovascular risk factor management is recommended and screening tools to distinguish between stage A and B heart failure in the community is required to individualise an intensification of therapy to those at highest risk,” said Dr Horgan.

He suggested programmes such as the ongoing St Vincent’s screening to prevent heart failure, or STOP HF study involve individualised screening strategies and shared care approaches may modify the course of Stage A/B heart failure in at-risk community populations.