495 - Dx and Tx HFpEF, Breast Cancer Screening, “Bumping” You Up

From the Literature and the American College of Cardiology (ACC)

1)  Dx & Tx of Heart Failure with Preserved Ejection Fraction (HFpEF)

Despite advances in therapy, heart failure (HF) continues to be a major cause of morbidity and mortality worldwide with a lifetime risk at age 40 years of approximately 20%. HFpEF now accounts for more than 50% of cases of HF, with outcomes comparable to heart failure with reduced ejection fraction (HFrEF). With recent advances in the understanding of HFpEF and improved methods of diagnosis, more effective management strategies are available by following guideline-directed medical therapy (GDMT).

The universal definition of HF requires symptoms and/or signs of HF caused by structural/functional cardiac abnormalities and at least 1 of the following: 1) elevated natriuretic peptides; or 2) objective evidence of cardio-genic pulmonary or systemic congestion. For HFpEF, the left ventricular EF threshold would be > 50%. Those individuals with EFs between 40-50% are considered to have HF with mildly reduced ejection fraction (HFmrEF).           Another major diagnostic challenge with HFpEF is that there is no single test that definitively establishes the diagnosis. Thus, it is paramount to consider potential mimics, both noncardiac and cardiac, that may present with signs of congestion and/or symptoms of dyspnea, exercise intolerance, or congestion with preserved EF.

With that as background, the ACC recently published an Expert Clinical Decision Pathway (ECDP) with the goal of providing timely and practical guidance on diagnosis and management of HFpEF. This document is aligned with and operates under the framework of the recommendations published in the recent HF guidelines but provides a nuanced approach regarding various aspects of care of the individual with HFpEF.

The role for primary care clinicians in this pathway includes recognizing HFpEF as a potential diagnosis in persons with dyspnea, exertional intolerance, and edema; initiating diagnostic testing and appropriate GDMT; and recognizing when a cardiology referral is warranted.

Although the universal definition of HF may be useful to guide clinicians, establishing a diagnosis of HFpEF may be more difficult given that the echocardiogram may not demonstrate obvious structural or functional cardiac abnormalities and the natriuretic peptide levels may be normal, especially in individuals with obesity. Given the lack of testing to definitively establish the diagnosis of HFpEF, the use of clinical scoring systems may be useful to aid in the diagnostic evaluation of suspected HFpEF. The H2FPEF score was derived and validated using a gold-standard reference of invasive exercise hemodynamic measurements and is considered a practical tool for use. The 6 components of the H2FPEF Score consist of information that is readily accessible: Heavy (body mass index [BMI]>30 kg/m2), Hypertension (on 2 or more antihypertensive medications), atrial Fibrillation, Pulmonary hypertension (estimated pulmonary artery systolic pressure>35 mm Hg on Doppler echocardiography), Elder (age>60 years),

Filling pressures (E/e’>9 on Doppler echocardiography). A score of 6 or more is highly suggestive of HFpEF.

Once the diagnosis is made, guideline-directed medical therapy is as follows:

MRA = mineralocorticoid antagonist 

ARNI = angiotensin-nephrilysin inhibitor

Non-pharmacologic management includes aggressive management of co-morbidities, including HTN, obesity, diabetes, a-fib, CAD, OSA, and CKD, and a guideline directed exercise prescription.

Referral for cardiology consultation should be considered for: 1) confirmation of the diagnosis and/or exclusion of other conditions; 2) optimization of risk factors and comorbidities; 3) assessment of prognosis and the potential for advanced HF therapies; and 4) establishment of a framework for ongoing collaboration with primary care clinicians, if needed, regarding management of HF symptoms, comorbid conditions, and prognosis

Mark’s Comments:

I often get the sense that HFpEF is often treated like “heart failure lite,” but the data indicates that is certainly not the case. It’s also important to note that “diastolic dysfunction” on echo is not diagnostic of HFpEF, though someone with diastolic dysfunction can certainly have HFpEF. It is notable that the FDA just expanded the indication of dapagliflozin to include treatment of HF across the full spectrum of LVEF.

Reference:         

·         Kittleson M, et al. 2023 ACC Expert Consensus Decision Pathway on Management of Heart Failure With Preserved Ejection Fraction: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol. 2023 May, 81 (18) 1835–1878. Link

From the US Preventive Services Task Force (USPSTF)

2)    Draft Changes to Breast Cancer Screening Recommendations

The US Preventive Services Task Force has released a new DRAFT recommendation for breast cancer screening, in which there are several changes of note. Per the USPSTF’s usual process, this recommendation is being released for public comment, and could be revised before the final recommendation.

It is important to note that there are no new controlled trials of breast cancer screening vs. no screening. The new recommendation is largely based on new epidemiological evidence, new evidence on detection rates for different tests, mixed evidence on testing frequency, and a new collaborative modeling study. The older, completed controlled trials demonstrating the impact of screening on breast cancer mortality are considered foundational, so modeling studies and the additional, more specific studies, have been used for a couple of decades to update the specifics of the recommendation.

The new (draft) recommendation is:

                 ·            The USPSTF recommends biennial screening mammography for women ages 40 to 74 years. B recommendation (moderate certainty of moderate net benefit)

·         The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening mammography in women age 75 years or older. I statement (insufficient evidence)

·         The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of supplemental screening for breast cancer using breast ultrasonography or magnetic resonance imaging (MRI) in women identified to have dense breasts on an otherwise negative screening mammogram. I statement (insufficient evidence)

Details of the recommendation and changes include:

·         Age range – For women aged 40-49 years, epidemiological studies reveal a greater jump (of 2%) in invasive breast cancer rates between 2015 and 2019 than between 2000 and 2014 for uncertain reasons. A “trial simulation” study (a type of modeling study) showed that the benefit of screening beyond age 70 persisted only until age 74 and not further. The collaborative modeling study showed an additional benefit of screening from age 40 to 74 (compared with age 50-74) of “1.3 additional breast cancer deaths averted per 1,000 women.”

·         Screening methods – for years we have seen the adoption of digital breast tomosynthesis (DBT, “3-D mammography”) in the clinical space, but the USPSTF had found no evidence to warrant its inclusion in the mammography recommendation. Recent data (3 randomized controlled trials (RCT) and a non- randomized trial) have shown equivalent detection rates between DBT and digital mammography (DM), and the inclusion of DBT in the modeling study revealed similar benefits to DM with fewer false positives. Of note, the USPSTF does not take cost into account. There was insufficient evidence to make a recommendation concerning the use of adjunctive breast ultrasound or MRI for average risk patients.

·         Screening intervals – The collaborative modeling study again revealed a better balance of benefits and harms (false positive results, unnecessary biopsies, etc.) with biennial screening throughout the recommended age range. The accumulated evidence from trials of yearly vs. biennial screening have shown no benefit to yearly screening over biennial.

                   ·          Disparities – There is a notable disparity in breast cancer mortality among Black women (approximately 40% higher compared with White women). They often have equal or slightly higher rates of screening but are diagnosed at a                                     greater stage on average and have higher rates of “triple negative” cancers (which have a worse prognosis). Adherence rates for long-term endocrine adjuvant therapy are lower in Black women due to a greater symptom burden from                              these therapies. More concerning is that screening follow up and treatment rates are lower in Black women and indirect evidence points to inequalities in resources, harmful exposures, and access to and delivery of high-quality                                            healthcare. While the evidence shows that Black women have the poorest health outcomes from breast cancer, the USPSTF calls for further research that emphasizes recruitment of women from all racial/ethnic groups.

John’s Comments:

Remember, this is a draft recommendation for now. The history of this recommendation is telling – you may recall the 2002 recommendation for screening every 1-2 years from ages 40-75. We are unlikely to have a large randomized controlled trial again, so the USPSTF’s job will continue to be to integrate evidence on the more focused questions of ages, intervals, and disparities. The evidence of disparities in care for Black women after screening emphasizes the need for us to work on our systems of care – handoffs, reminders, surveillance – so that all our patients can benefit from this screening.

Reference:

·         Draft Recommendation: Breast Cancer: Screening | United States Preventive Services Taskforce. Accessed May 10, 2023. Link

From PeerRxMed ( www.PeerRxMed.org )

3)    It’s Time to “Bump” You Up

“High fives and fist bumps … have a lot to say about the cooperative workings of a team ….” Kraus, Huang, and Keltner (2010)

Those of you who’ve been around me know that expressing encouragement and connection is important to me, and one of my favorite ways of doing so is to share a smiling, look-you-in-the-eyes greeting accompanied by a high-five, fist-bump, or elbow- bump when I see you. It is important to me that you feel seen. This behavior has been reduced over the past 3 years to smile-with-my-eyes smiles and “air bumps” or an occasional “daring” elbow bump. All this made the recent AAFP Physician Well-being Conference feel all the more exhilarating as I was able to break out my full repertoire once again with hundreds of kindred spirits who were equally eager to reconnect.

Since we humans are relational by nature, it should come as no surprise that there is evidence that such physical connection likely helps to improve team performance and promotes cooperation and trust – even at the level of professional athletes. In 2010, Michael Kraus and colleagues published a study titled “Tactile Communication, Cooperation, and Performance: An Ethological Study of the NBA” (Link). Their hypothesis was that in group competition, physical touch would predict increases in both individual and group performance.

They focused their analysis on 12 distinct types of touch that occurred when two or more players were in the midst of celebrating a positive play that helped their team (e.g., making a shot). These celebratory touches included fist bumps, high fives, chest bumps, leaping shoulder bumps, chest punches, head slaps, head grabs, low fives, high tens, full hugs, half hugs, and team huddles.

Consistent with their premise, those teams with higher early season touch achieved greater performance for both individuals and teams later in the season, even after accounting for player status, preseason expectations, and early season performance. This success appeared to be explained by greater cooperative behaviors between teammates in the higher-touch groups. And while the authors acknowledged these results were not immediately applicable to other groups, they did wonder as to how the cumulative effect of such seemingly insignificant acts might enhance group cooperation and performance in other settings.

Of course, none of our care teams are vying for an NBA title and we’re certainly not going to high-five and fist-bump our way out of our present challenges. At the same time, I would undoubtedly rather be part of a team in which we’re both addressing the needs of the group AND regularly acknowledging and encouraging each other while carrying out our good and challenging work. If high-fives and fist-bumps provide a needed boost for elite athletic teams, they certainly seems worth a try in the clinical setting. At the least, doing so would likely “bump you up” for the day, and we could sure all use some of that right now.

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Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org