Melanie Cole, MS (Host): Welcome to Better Edge, a Northwestern Medicine Podcast for physicians. I'm Melanie Cole. And today, our discussion focuses on Prevent HF, the new AHA statement on how to apply a risk-based prevention strategy for heart failure, similar to what's long been used for heart attack and stroke. Joining me is Dr. Sadiya Khan. She's the Magerstadt Professor of Cardiovascular Epidemiology and an Associate Professor of Medicine in Cardiology at Northwestern Medicine.

Dr. Khan, thank you so much for joining us today. As we get into this topic, can you provide a little context on the current state of heart failure in the United States today and how the need for a heart failure prevention paradigm led to the AHA's creation of Prevent HF.

Sadiya Khan, MD: Thanks, Melanie for having me. I was really excited when you reached out, because I think there's no greater public health and clinical problem today than preventing and managing heart failure. We know that nearly seven million Americans are living with heart failure, and that number is projected to exceed 11 million by 2050 if current trends continue. We also know there's no cure for heart failure. Once someone is hospitalized with heart failure, we have therapies and devices that we use to try to prolong life and minimize symptoms, but there is no way to return to that pre-heart failure stage.

For those reasons, we have been working towards trying to develop a clinical care algorithm approach to help prevent heart failure. The most important thing we can do is identify those who are at risk and employ evidence-based therapies that currently exist to prevent that progression. And I think we have the tools now to be successful in doing this. And all of this kind of came together all at the same time where we had development and available data to be able to create a risk tool. We had new therapies that were available that could prevent progression and this understanding that this is a critical time to start to address this problem.

Melanie Cole, MS: Well, it certainly is a complex situation. So, what were the key considerations in the development of Prevent HF equations? How do these work within and build upon the existing guidelines we have now?

Sadiya Khan, MD: One of the things we were really looking to learn from was the success of the current cholesterol and primary prevention guidelines that have relied on risk equations, first, the Framingham Heart Score, and more recently the pooled cohort equations to say what went into those equations that made them successful to be able to be used in clinical practice. And we identified several things.

First was making sure that the predictors in the risk equation were traditional risk factors that we were already assessing in the primary care setting: incorporating blood pressure levels, body mass index is an important predictor, kidney function is an important predictor into these models made it useful, and also easily implementable, because these are things we're already assessing in our patients.

While there are some interesting biomarkers that could be useful, like BNP or high-sensitivity troponin that have been shown in research studies to be associated with risk of heart failure, we didn't want to create a paradigm that required new testing, more testing or increase in healthcare costs.

Melanie Cole, MS: This is so interesting and important as you're telling us about risk-enhancing factors that Prevent HF takes into account. Tell us a little bit about the importance of considering non-traditional risk factors into heart failure projection and diagnosis. You mentioned BMI. And certainly, we think of lifestyle behaviors, modifications, those sorts of things. What are some of the non-traditional ones we might not think about?

Sadiya Khan, MD: It's a really important question when we think about heart failure is such a heterogeneous condition. People develop heart failure for different reasons. And while we know there are some core or central traditional risk factors like hypertension and diabetes, there's also a lot of other conditions that have been associated with risk of heart failure, such as chronic inflammatory disease, living with HIV or AIDS, exposure to cardiotoxins, particularly after breast cancer treatment for women. Adverse pregnancy outcomes and metabolic dysfunction-associated steatotic liver disease or MASLD, which used to be referred to as NAFLD or non-alcoholic fatty liver disease. And these are common conditions that many people are experiencing. And so, being aware of this broader array of potential risk factors can also be helpful in identifying risk in speaking with patients about their risk for heart failure. Because as you pointed out, there's lots of strategies to reduce risk, including lifestyle, behavior modifications, reducing sodium intake, lowering blood pressure through increasing physical activity, weight loss, as well as therapeutic options. We know with the emergence of GLP-1 RAs like Ozempic and SGLT-2 inhibitors like Jardiance, that there's a lot of therapy options as well to lower that risk if we can identify the right patient to deliver that therapy to.

Melanie Cole, MS: Statins are playing a big role in this, aren't they now?

Sadiya Khan, MD: Statins have been one of the most Impactful advances of the last several decades, they have led to a remarkable decline in ischemic cardiovascular disease mortality, and we've seen more than a 50% reduction in the last three decades in ischemic cardiovascular disease mortality in the United States. So, we've had such remarkable progress. But for heart failure, cholesterol is not as central a driver. And so, we know that it's important to prevent ischemic heart disease to prevent heart failure as a downstream consequence. But focusing on healthy weight, healthy blood pressure, and reducing risk of diabetes are much more central to preventing heart failure.

Melanie Cole, MS: So, what impact then, does early detection have on heart failure patient outcomes? What have you seen?

Sadiya Khan, MD: We know that earlier detection, earlier diagnosis, can lead to better outcomes. What we don't want are people who are arriving in the emergency room decompensated because they have frank volume overload when it could have been identified earlier. And I think as we've really understood better the tools like electrocardiogram and echocardiogram for identifying risk. We can also think about how they can be used to detect risk, so when patients are starting to have the earliest signs and symptoms so that we can intervene sooner and lead to better outcomes and prevent hospitalizations, which is really ultimately one of the most impactful things we can do for our patients' lives.

Melanie Cole, MS: Dr. Khan, then how is Prevent being incorporated into clinical practice, and what are the implications for care at Northwestern Medicine Bluhm Cardiovascular Institute? Take us from bench to bedside here and how these types of guidelines and statements really work for better patient outcomes.

Sadiya Khan, MD: Yes, Melanie, this is such an important point. Risk equations are only as useful as they are once they're used, and so we wanna make sure that we can help to implement these so that they are easily translatable into the clinic and help to guide patient care. The American Heart Association and American College of Cardiology are currently updating their prevention guidelines to evaluate how best to assess risk for atherosclerotic or ischemic heart disease, as well as heart failure. And while we await those guidelines.

I think what we can say right now is that the prevent equations offer a more accurate way to estimate risk. They offer a 10-year and 30-year risk estimate, and they allow risk estimation separately for atherosclerotic disease and heart failure. So, we have this information, but we are still waiting for how best to implement it. And while we're preparing for that, particularly here at Bluhm Cardiovascular Institute, one of the things we want to be ready for is having this built into our electronic medical record system so we can support clinicians in being able to easily access the risk assessment at their fingertips through automated platforms.

Melanie Cole, MS: This is a great discussion, Dr. Khan, and the paper outlines several opportunities for additional research, including opportunities for further improvement of risk calculation with clinician involvement in the use of artificial intelligence. This is a burgeoning field. How do you see these and other advances helping heart failure, risk prevention, evolving? What do you see happening in this?

Sadiya Khan, MD: AI is such an exciting area right now, and there's so many opportunities. I think one of the most important things is trying to identify how it can best improve assessment as well as implementation. We know that large language models can be very useful in identifying risk factors. For example, some of the non-traditional risk factors we spoke about, could we better go through the medical record and identify who may have risk for those and bring it into one place so that we can actually find the information more easily? Could we use AI to review our echocardiographic images so that we can make sure that we're not missing key findings? As well as help use AI to nudge in terms of what are the best evidence-based therapies for patients and making sure that they have access to those, I think are some ideas for how we can potentially leverage this exciting area. But there's a lot more research that needs to be done and so I think it's a really exciting time to think about these opportunities.

Melanie Cole, MS: It certainly is. Thank you so much, Dr. Khan, for joining us today and sharing your expertise on the new statement. Thank you again. And to refer your patient or for more information, please visit our website at breakthroughsforphysicians.nm.org/cardiovascular to get connected with one of our providers. That concludes this episode of Better Edge, a Northwestern Medicine Podcast for physicians. I'm Melanie Cole.