Biomarker-guided early heart failure assessment in hospitalized patients with tachypnea: results from the Akershus Cardiac Examination 4 Study
R Bhatnagar, K Lippestad, T Wisloff, A Gjorven, L G Klaebo, A D Hoiseth, T Omland, H R Rosjo, M N LyngbakkenAbstract
Background
Patients hospitalized with acute tachypnea have high morbidity and mortality, frequently caused by acute heart failure (AHF). Guidelines provide clear cutoffs for N-terminal pro–B-type natriuretic peptide (NT-proBNP) and cardiac troponin T (cTnT) concentrations to diagnose AHF and myocardial infarction. As early recognition of AHF remains challenging, a strategy of structured biomarker-guided assessment integrated into the electronic health record (EHR) of patients could reduce HF-related hospitalizations and mortality compared to standard care.
Purpose
To examine whether early cardiac assessment guided by NT-proBNP and cTnT, combined with structured EHR-based feedback, improves clinical outcomes compared to standard of care.
Methods
The Akershus Cardiac Examination (ACE) 4 Study was a pragmatic, single-center, randomized controlled trial including adult patients hospitalized with acute tachypnea (respiratory rate ≥20 breaths/min) in the Emergency Department. Participants were randomized to biomarker-guided cardiac evaluation with standardized EHR recommendations (intervention group) or standard care (control group). The biomarker algorithm was used to estimate the likelihood of AHF and guide further diagnostic evaluation and management. The primary endpoint was time to all-cause mortality or hospital readmission within 12 months of randomization. Statistical power analysis defined the need for 152 participants in each treatment arm. To account for potential drop-out and planned subgroup analyses, the target enrollment was 500–600 participants.
Results
From April 27, 2023, to March 20, 2024, a total of 573 patients were randomized to the intervention (n = 286) or control group (n = 287). Baseline characteristics were well balanced between groups, with similar age (median 74 years), sex distribution, and prevalence of cardiovascular comorbidities (Table). During 12 months of follow-up, the primary composite endpoint of hospital readmission or all-cause death occurred in 46% of patients in the intervention group and 44% in the control group. Kaplan–Meier curves showed no significant separation between groups (Figure). In age- and sex-adjusted Cox regression analysis, the intervention was not associated with a reduction in the primary endpoint (HR 0.92, 95% CI 0.72–1.17; p = 0.50). Similar findings were observed for readmission and mortality analyzed separately.
Conclusion
In this pragmatic randomized trial of unselected patients hospitalized with acute tachypnea, early biomarker measurement combined with structured EHR feedback did not reduce the risk of hospital readmission or all-cause mortality at 12 months compared with standard care.Figure