Improving early diagnosis and prevention of HF

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HF is often diagnosed late in the course of the disease. Approximately 50% of initial diagnoses are made in the emergency department when patients present with acute decompensation. For many patients, this is the most distressing and confusing period of their HF journey. There are several reasons for delay in the diagnosis of HF. These include a lack of awareness of HF in the general population (so that people with symptoms do not seek medical attention) and inadequate diagnostic tools in primary care. In addition to working with Heart and Stroke to improve awareness of HF, this team will use new technologies and AI to help diagnose HF in primary care. 

One of the studies that will help achieve this goal is the MAPLE-CHF study.

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MAPLE-CHF: Multidisciplinary Approach for high-risk Patients Leading to Early Diagnosis in Canadians with Heart Failure.

The MAPLE-CHF study is the Canadian arm of the SYMPHONY (Screening for earlY heart failure diagnosis and Management in Primary care or at HOme using Natriuretic peptides and echocardiographY) study, an international collaboration of 5 randomized controlled trials screening for HF using common study design elements and endpoints in 5 respective countries (Canada, Scotland, Sweden, Denmark, United States). In each country, individuals will first be pre-screened for HF risk factors. 

The primary objective of MAPLE-CHF is to evaluate whether a strategy of NT-proBNP and AI echocardiography in primary care increases the number of patients diagnosed with HF at 6 months, compared with usual care. This study will recruit participants in British Columbia and Quebec and will be led by Dr. Anique Ducharme (Montreal Heart Institute) and Dr. Nathaniel Hawkins (University of British Columbia). The recruitment is ongoing in both provinces. 

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PHARM-HF and OPTIMED-IC

On the other hand, pharmacists play an integral role in the prevention of worsening HF, particularly through medication optimization. Indeed, several high-quality RCTs have shown that having a pharmacist on the team caring for patients with HF improves outcomes. In January 2021, pharmacists in Vancouver established the PHARM-HF (Pharmacist-led Rapid Medication optimization for Heart Failure) clinic model, a virtual, remote-based, pharmacist-led outpatient clinic specializing in HF medication optimization. Patients are followed for a short period of time (3-4 months) with frequency (every 1-2 weeks) and then discharged back to their referring cardiologist. Early data has shown promising results in terms of improving the optimal medical therapy score. Based on these promising results, the team initiated the PHARM Optimal-HF pilot study, a local implementation of the PHARM-HF clinic, in which 60 eligible HF patients were randomized to either usual care or intervention (usual care + referral to the PHARM-HF clinic for medication optimization). Patients were followed remotely at 3, 6 and 12 months. The study evaluated the feasibility of implementing this model on a larger scale and measures the modified Optimal Medical Therapy Score and patient-reported outcome measures using questionnaires. The recruitment and follow-up phases are terminated. This pilot study is funded by the Canadian Foundation for Pharmacy and recruitment is ongoing.

In a cost-effectiveness analysis (in press), the team found that pharmacist/nurse practitioner-led HFrEF GDMT optimization was cost-effective, with an incremental cost-effectiveness ratio of $7437 per quality-adjusted life year compared with usual care, and an incremental net monetary benefit of $75,032. This is an important discovery as it provides support to expand medication management led by pharmacists and NPs, offering a scalable implementation strategy to address persistent evidence-to-practice gaps in HFrEF GDMT use in Canada (and worldwide).

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In parallel, a team from the Province of Quebec is also developing the OPTIMED-IC study in which community pharmacists will optimize treatment of HF patients, in collaborations with the patient's physician. The protocol is being finalized.  A survey of cardiologists and community pharmacists in Quebec revealed that there is merit in shifting the responsibility for medication optimization to pharmacists (paper under review). The study is scheduled to be submitted to the ethics committee by fall 2026.

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SAND-HF

Over the last year, the Access team developed the new pilot study SAND-HF for Spot Analysis of Natriuresis to guide up- or down-titration of Diuretic therapy in ambulatory patients with Heart Failure. The SAND-HF study will use a point-of-care device to test how specific and reliable a “spot urine sodium” measurement is in guiding diuretic use. By checking sodium (salt) levels in urine shortly after patients take their medication, researchers aim to see if this method can provide clearer, more personalized treatment decisions. This pilot study will randomized 300 patients and follow them for 90 days, tracking symptoms, quality of life, and kidney function. Outcomes include feasibility outcomes and the potential primary endpoints are the difference in congestion score at 90 days and the percentage on reduced diuretic dose at 90 days. Additional assessments include: KCCQ, loop diuretic dose and GDMT utilization, difference in NT-proBNP, weight, and NYHA at 90 days, accuracy of POC device, and system usability scale.

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The results will help determine whether a larger trial could transform how diuretic (water) pills are prescribed—making heart failure treatment safer and more precise. If successful, SAND-HF could lay the groundwork for more precise, personalized, and safer use of water pills in people living with heart failure.

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This study is led by Dr. Nathaniel Hawkins and Dr. Amitai Segev (both from UBC). The recruitment is ongoing.

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Cardiac function in patients with non-ischemic cardiomyopathy

Prevention and ealry diagnosis of HF could also be done through genetics analyses, as proposed in the Genetics and outcomes of dilated cardiomyopathy in the heart faiure clinic study. 

Heart failure clinics care for patients with a variety of heart problems, most commonly weaknesses in heart muscle function. We believe that a large number of patients with poor heart muscle function, or cardiomyopathy, can be explained by genetics. It is likely that depending on the genetic problem, some can improve with medications, but others will continue to deteriorate, which is why it is important to know the cause of the disease in order to adapt our treatments. Moreover, some cardiomyopathies run into families, and genetic testing can help determine if family members need to be screened for heart problems, to prevent complications. In this study, we will utilize data from selected patients with cardiomyopathy at the Montreal Heart Institute Heart Failure Clinic to understand if genetics influence presentation, response to treatment, and prevention of health problems in family members. The descriptive objectives are to determine the proportion and nature of genetic variants and family disease in patients with dilated cardiomyopathy (DCM) at the HF clinic, according to the subtype of DCM, and to describe the DCM echocardiography phenotype at baseline according to genotype. The predictive objectives are to identify whether the DCM subtype and genotype are associated with HF outcomes, and to assess for the presence of interaction between environmental factors and genotype on outcomes. Dr. Maxime Tremblay-Gravel, a cardiologist at the Montreal Heart Institute and recipient of an Early Career Investigator Grant from the CHF Alliance, leads this retrospective cohort study.