Natriuretic Peptide Screening for Primary Prevention or Early Detection of Heart Failure: A Pharmacist-Driven Team-Based Approach
Background: Emerging data indicates that natriuretic peptide biomarker-based screening and early intervention could prevent left ventricular dysfunction or new-onset heart failure (HF). The 2017 update of the American College of Cardiology/American Heart Association/Heart Failure Society of America guideline for managing HF provides a IIa recommendation for natriuretic peptide biomarker screening followed by a team-based approach for preventing HF.
Observations: Clinical pharmacists worked collaboratively with a cardiology specialist and primary care practitioners to establish a protocol to identify patients at risk for HF. Patients with hypertension and/or type 2 diabetes mellitus (T2DM) and without a history of HF with N-terminal pro-B-type natriuretic peptide > 125 pg/mL received follow-up from clinical pharmacists, including initiation and/or adjustment of renin-angiotensin system inhibitors, discussion of echocardiogram, and comprehensive disease state management of hypertension, T2DM, atherosclerotic cardiovascular disease risk reduction, oral nonsteroidal anti-inflammatory drug reduction, and tobacco cessation.
Conclusions: By using natriuretic peptide screening, clinical pharmacists were able to identify patients with hypertension and/or T2DM who were at higher risk for HF and provide comprehensive medication management.
The percentage of patients in this project with risk factors for HF and an elevated NT-proBNP were similar to the elevated levels described in the STOP-HF trial. In our project, 32.9% of patients had elevated NT-proBNP levels, similar to the 41.6% of patients in STOP-HF. Among the completed echocardiograms, 16% revealed mildly reduced or reduced EF. These patients were identified early in the disease course before symptom onset and received intervention with RAS inhibitors and disease state management.
In addition to early identification of reduced EF, this project allowed a targeted approach to identifying patients for risk factor reduction. Between the 2 PACT teams, 246 patients with T2DM and/or hypertension were seen from September 2019 to January 2020. By using natriuretic peptide screening, the clinical pharmacists were able to prioritize and focus risk factor management on patients at higher risk. Pharmacists were then able to intervene for all risk factors assessed: hypertension, T2DM, ASCVD risk reduction, NSAID use reduction, and tobacco cessation.
During the implementation period, VA criteria of use of the angiotensin receptor-neprilysin inhibitor, sacubitril/valsartan, was restricted to VA cardiology. For patients with reduced EF, it was up to the PCP’s discretion to consult cardiology for further follow-up. In November 2020, the VA removed the restriction to cardiology and PCPs were able to order sacubitril/valsartan. Although not included in the Figure at the time of project implementation, the clinical pharmacist could now transition a patient with reduced EF from a RAS inhibitor to sacubitril/valsartan and adjust to target dosages.
Clinical pharmacists involved in this project had established working relationships with each of the PACT members before project initiation. The PACT employed the clinical pharmacists regularly for chronic disease state management. This facilitated adoption of the natriuretic peptide screening process and PCP buy-in and support. The PCPs agreed to discuss adding a NT-proBNP laboratory test with the patient, when possible, during their in-person appointment and informed the patient that a pharmacist would call if the result was elevated. This warm hand-off facilitated the patient’s reception to the clinical pharmacists’ recommendations after an elevated NT-proBNP result. We also reported PCPs’ high acceptance rate of pharmacist recommendations and interventions for disease state management. These high acceptance rates reflect the established working relationships between clinical pharmacists and the PACT.
Development of templated notes, medication adjustment schedules, and telephone script allowed for consistent implementation into the PACT panels. This process could be duplicated and adopted into other PACTs who want to use a clinical pharmacist to facilitate natriuretic peptide screening and risk factor reduction. The findings from this project can be extrapolated to other team-based care such as the patient-centered medical home model because these programs exhibit many similarities. Both health care models centralize patient care and use interdisciplinary care teams to promote continuity, care coordination, and access to achieve optimized patient outcomes.
Cost was an important factor to consider when implementing this project. With an increase in prescriptions and elective, outpatient echocardiograms, higher outpatient cost is expected. A cost-effectiveness analysis in the STOP-HF trial found an overall cost benefit by reducing the number of patients diagnosed with left ventricular dysfunction or HF and emergency hospitalizations for cardiac events in those who received collaborative care after natriuretic peptide testing.8 These cost savings offset increased outpatient costs.
Limitations
Participants were identified initially through a computer-generated list of patients with hypertension or T2DM without a HF diagnosis documented in their problem list. This problem list is manually updated by PCPs. Although we reviewed records for exclusion criteria, eligible patients might have been excluded. The use and interpretation of an NT-proBNP level is not specific to cardiac disease. Elevations can be seen with increased age, kidney dysfunction, and pulmonary disease. Additionally, an NT-proBNP level might be falsely low in patients who are overweight or obese. Because of the relatively short period of time, we could not analyze associations with HF diagnosis or progression, hospitalizations due to HF, or mortality. Regarding external validity, because of the pre-established interdisciplinary clinic settings and VA pharmacists’ scope of practice with prescriptive authority, implementing this project might have been better received by PCPs and allowed for higher acceptance rates of pharmacist interventions at the VA compared with a community setting.
Conclusions
The ACC/AHA/HFSA guidelines recommended use of natriuretic peptide biomarker screening in conjunction with team-based care for those at risk of developing HF. We describe our process for implementing team-based care using clinical pharmacists in primary care. Our process provides a targeted approach to identifying patients for risk factor reduction through comprehensive medication management and could be replicated by other primary care clinics using a patient-centered medical home model.
Acknowledgments
We would like to acknowledge Dr. Sara Hariman, Dr. Payal Sanghani, and Dr. Cecilia Scholcoff for their support and collaboration with the project.
