Biomarker-guided HF: What have we learned (so far)?

Biomarker-guided HF: What have we learned (so far)? James L. Januzzi, Jr, MD, FACC, FESC Associate Professor of Medicine Harvard Medical School Director, Cardiac ICU Massachusetts General Hospital

DECLARATION OF CONFLICT OF INTEREST Grants: Roche Diagnostics, Siemens, Critical Diagnostics, Thermo-Fisher Consulting: Roche Diagnostics, Critical Diagnostics

BNP/NT-proBNP and Stage C HF Prognosis

The Importance of Serial NP Measurements for Prognostication in Chronic HF Masson, et al, J Am Coll Cardiol 2008

Therapies with Effects on B-Type Natriuretic Peptide Levels Therapy Diuresis ACE-I ARB -blockers Aldosterone antagonists BiV pacing Exercise Rate control of AF BNP infusions Effect on BNP/NT-proBNP Some transiently, most N-BNP, BNP then

Rationale for guided therapy Proactively identify those on an inadequate medical program Reactively identify those at high risk for impending complication Directly address the underlying biology of HF guided by tools that reflect it

Patients (%) Baseline Quality of Outpatient HF Care Conformity with Quality Measures at Baseline 100 90 80 70 60 50 40 30 79.8 86.2 34.4 CRT-P only 68.6 CRT-D 37.7 6.3 ICD only 48.8 31.7 61.8 20 31.4 10 17.2 0 ACEI / ARB Beta-Blocker Aldosterone (N = 11,165/ (N = 11,868/ Antagonist 13,987) 13,772) (N = 987/ 2827) Anticoagulation for Atrial Fibrillation (N = 2910/ 4244) CRT (CRT-D / CRT-P) ICD / CRT-D HF Education (N = 580 /1540) (N = 4799/ 9830) (N = 9373/15,177)

Use of Guideline Recommended Therapies at Baseline, 12, and 24 Months Longitudinal p=<0.001 p=0.001 p=0.001 p=<0.001 p=0.001 p=0.778 p=0.546 p=0.001 p=<0.001 p=<0.001 p=0.001 p=0.001 p=<0.001 p=<0.001 The P-values for 12 and 24 month outcomes are compared to baseline.

Results of biomarker guided HF trials Positive Negative Troughton et al STARS-BNP Berger, et al, 2010 PROTECT STARBRITE PRIMA SIGNAL BATTLESCARRED* TIME-CHF* *Positive for those patients aged <75 years

Event free survival % STARS BNP guided HF therapy: STARS BNP 100 90 80 70 60 50 Clinical group BNP group P <.01 Treatment modifications (n) 60 50 40 30 20 10 0 BNP Control T (days) Diuretics ACEI BB Spiro Other Jourdain, et al, JACC, 2007

NT-proBNP and HF Outcomes TIME-CHF 499 subjects with systolic HF, recent event, randomized to NT-proBNP versus Standard HF management 18 month follow up: Endpoint Overall <75 years 75 years Hosp-free survival 0.92 (0.73-1.15) 0.76 (0.53-1.09) 1.06 (0.79-1.43) Survival 0.68 (0.46-1.01) 0.38 (0.18-0.80) 2 0.92 (0.57-1.49) HF hosp-free survival 0.66 (0.49-0.90) 1 0.41 (0.23-0.72) 3 0.86 (0.59-1.24) 1 P =.008; 2 P =.01; 3 P =.002

NT-proBNP and HF Outcomes TIME-CHF Why did the elderly in TIME-CHF and BATTLESCARRED show less of a response to guided therapy? 1) Comorbidities 2) More HFpEF (in B SCARRED) 3) The elderly require special treatment Endpoint Overall <75 years 75 years Hosp-free survival 0.92 (0.73-1.15) 0.76 (0.53-1.09) 1.06 (0.79-1.43) Survival 0.68 (0.46-1.01) 0.38 (0.18-0.80) 2 0.92 (0.57-1.49) HF hosp-free survival 0.66 (0.49-0.90) 1 0.41 (0.23-0.72) 3 0.86 (0.59-1.24) Guided therapy is not a one size for all approach!

Understanding the heterogeneity of results in guided therapy trials Age HFpEF? Low target NP? NP reduced significantly? Did NP guidance change therapy? STARBRITE 60 No No No Yes TIME-CHF 77 No Yes No Yes B SCAR 76 Yes Yes No Yes PRIMA 72 Yes No No No SIGNAL 78 No No No No Troughton 70 No Yes Yes Yes STARS 65 No Yes Unknown Yes Berger 71 No Yes Yes Yes PROTECT 63 No Yes Yes Yes Januzzi, J Card Fail., 2011

PROTECT Study Design Patient with Class II-IV symptoms, EF 40%, recent HF event Randomization echocardiogram Standard evaluation + NT-proBNP Minnesota Living With HF Questionnaire quarterly Standard evaluation Minnesota Living With HF Questionnaire quarterly Therapy adjusted to achieve optimal drug targets PLUS NT-proBNP <1000 ng/l Visits q3 months Extra visits as needed Therapy adjusted to achieve optimal drug targets Visits q3 months Extra visits as needed Close-out echocardiogram Total cardiovascular events at 1 year

NT-proBNP Concentrations Baseline Follow-up P Overall 2118 [1122-3831] 1321 [554-3197].02 By treatment allocation Treatment Baseline Follow-up P SOC 1946 [951-3488] 1844 [583-3603].61 NT-proBNP 2344 [1193-4381] 1125 [369-2537].01 P =.40 for SOC baseline versus NT-proBNP baseline

Primary Endpoint 120 100 100 events P =.009 SOC NT-proBNP Number of events 80 60 40 20 58 events *Logistic Odds NT-proBNP = 0.44 (95% CI=.22-.84; P =.019) Number needed to guide (NNG) to prevent one event: 1.8 patients NNG to prevent one HF hospitalization: 4.8 patients 0 Total CV Events *Adjusted for age, LVEF, NYHA Class, and egfr

Safety % with events 8 7 6 5 4 3 2 1 0 Acute renal failure Acute renal failure Dizziness Dizziness Hypo/hyperkalemia Hypo or hyperkalemia Adverse events Hypotension Hypotension SOC NT-proBNP P =.72 P =.70 P =.32 P =.08 P =.47 Syncope Syncope

Elderly Benefit Similarly as Nonelderly HF Patients Logistic Odds of Mean Number of Cardiovascular Events P interaction =.11 Adjusted logistic odds GEE = 0.24 (p=0.008) Adjusted logistic odds GEE = 0.61 (p=0.100) Age Categories

Understanding the results in PROTECT and TIME/B SCARRED witn respect to the Elderly No HFpEF in PROTECT (cf B SCARRED) Patients in PROTECT were seen as frequently as needed; the elderly were cared for quite differently, with more visits (7.5 versus 5.0; P =.001) and more gradual up-titration of therapies By the end of the study, elderly and non-elderly were on similar medication programs Elderly patients in the guided therapy arm had no increase in AE s compared to younger patients

Guided therapy supplements clinical judgment! It does not replace it! When applied combined with good clinical judgment, guided therapy is not only successful, it is well-tolerated, even in the most complex patients

Are there biological benefits from natriuretic peptide lowering? Can we foster improved cardiac structure and function with biological manipulation of the heart? 1 week 3 months

Guided therapy and change in echocardiographic parameters % change 10 5 0-5 -10-15 LVEF P =.01 LVESVi P <.001 LVEDVi P <.001 E/E P =.03 E/E >15 P <.001 RVSP P <.001 RVFAC P =.01-20 -25 SOC NT-proBNP -30

The Importance of Serial NP Measurements for Prognostication in Chronic HF Masson, et al, J Am Coll Cardiol 2008

NT-proBNP (pg/ml) Outcomes as a function of response to guided therapy 3000 2500 Group High/High Mean CV events 1.57* 2000 1500 Low/High 0.71 1000 500 High/Low 0.46 Low/Low 0.50 0 Baseline Follow up * p = 0.003 versus Low/Low group, p = 0.002 versus High/Low group

Time in response and outcomes 0.09 Mean Cardiovascular Events 0.08 0.07 0.06 0.05 0.04 0.03 0.02 0.01 p < 0.0001 0 1 2 3 Percent Time in Response Score (Tertile) More time in response (NT-proBNP 1000 pg/ml)

What is the future of guided therapy? Assessment of other markers Pivotal multi-center trials Larger office-based guided therapy studies Home testing

Candidate 2 nd line biomarkers for guided therapy Injury biomarkers Highly sensitive troponin Fibrosis biomarkers Soluble ST2 Galectin-3 GDF-15 Vascular stress biomarkers Mid-regional pro-adrenomedullin Co-morbidity biomarkers Copeptin (hyponatremia) Uric acid Renal function/injury NB: In the future, any biomarker we add to the management of patients with HF must add significant value above-andbeyond natriuretic peptides for: Drug choices Prognostication Decisions re: invasive management

What is the future of guided therapy? Assessment of other markers Pivotal multi-center trials Larger office-based guided therapy studies Home testing

HF Assessment with BNP in the Home (HABIT) Study Patients discharged from hospital for HF with BNP > 400 pg/ml Outpatient decompensation Daily finger-stick measurement of BNP at home (patient and MD blinded) x 60 days > 150 have completed this pilot study; results expected at HFSA

BNP pg/ml 1200 1000 800 Home BNP measurement 60 year old female NYHA=II LVEF=20% BNP(adm) = 635 pg/ml 600 400 200 0 0 10 20 30 40 50 60 70 Day

Summary The use of objective tools to recognize HF, stratify its risk, and guide its management improves diagnosis and triage, and leads to better utilization of appropriate therapies. The use of natriuretic peptides to objectively guide HF therapy is a promising approach. Higher risk patients are identified, with opportunities to fine tune medical and non-medical therapies When properly applied, the approach is well-tolerated

Summary In order for guided therapy to be successful: It is best applied in HF due to LVSD A low NP goal must be attempted Therapies must be changed in an effort to achieve this goal and tailored to the individual patient The closer the NP achieved is to the goal (and the longer one remains at or near it) the better

Summary When guided therapy is used: Older patients may require a different approach than younger, but their care may be improved with biomarker guidance Non-responders have a bad prognosis and an alternative approach for their care is necessary

Biomarker-guided HF: What have we learned (so far)? James L. Januzzi, Jr, MD, FACC, FESC Associate Professor of Medicine Harvard Medical School Director, Cardiac ICU Massachusetts General Hospital