Effects of Atrial Fibrillation Screening According to N-Terminal Pro-B-Type Natriuretic Peptide: A Secondary Analysis of the Randomized LOOP Study

Systematic screening for atrial fibrillation with non-invasive devices: a systematic review and meta-analysis

Background

Systematic screening individuals with non-invasive devices may improve diagnosis of atrial fibrillation (AF) and reduce adverse clinical events. We systematically reviewed the existing literature to determine the yield of new AF diagnosis associated with systematic AF screening, the relative increase in yield of new AF diagnosis with systematic screening compared to usual care, and the effect of systematic AF screening on clinical outcomes compared with usual care.

Methods

The Medline, Embase, Web of Science and Cochrane Library databases were searched from inception through 1st February 2025 for prospective cohort studies or randomised clinical trials (RCTs) of systematic AF screening with the outcome of incidence of previously undiagnosed AF from screening. Incidence rates (IR) and relative risks were calculated and random effects meta-analysis performed to synthesise rates of AF in prospective cohort studies and RCTs, as well as outcomes in RCTs.

Findings

From 3806 unique records we included 32 studies representing 735,542 participants from 8 RCTs and 24 prospective cohorts. The diagnosis rate for incident AF in prospective cohorts was 2.75% (95% CI 1.87-3.62), and the pooled relative risk in RCTs was 2.22 (95% CI 1.41-3.50). The use of age and NT-proBNP (IR 4.36%, 95% CI 3.77-5.08) or AF risk score classification (4.79%, 95% CI 3.62-6.29) led to higher new AF diagnosis yields than age alone (0.93%, 95% CI 0.28-2.99). Pooled data from RCTs did not demonstrate an effect of screening on death (RR 1.01, 95% CI 0.97-1.05), cardiovascular hospitalisation (1.00, 95% CI 0.97-1.03), stroke (0.95, 95% CI 0.87-1.04) or bleeding (1.08, 95% CI 0.91-1.29).

Interpretation

Systematic screening for AF using non-invasive devices is associated with increased diagnosis of AF, but not reduced adverse clinical events. Screening studies of AF utilising alternative risk stratifications and outcome measures are required.

Funding

British Heart Foundation (grant reference CC/22/250026) and National Institute for Health and Care Research.

Effects of Atrial Fibrillation Screening According to Thyroid Function: Post Hoc Analysis of the Randomized LOOP Study

CONTEXT

Subclinical thyroid dysfunction is a marker for atrial fibrillation (AF) and stroke risk.

OBJECTIVE

This study explored the effects of AF screening according to thyroid-stimulating hormone (TSH) levels.

METHODS

An AF screening trial (the LOOP study) was analyzed post hoc according to baseline TSH. The primary outcome was stroke or systemic embolism (SE). Secondary outcomes included major bleeding, all-cause death, and the combination of stroke, SE, and cardiovascular death.

RESULTS

TSH measurements were available in 6003 of 6004 trial participants, 1500 randomized to implantable loop recorder (ILR) screening for AF and anticoagulation upon detection vs 4503 to usual care; mean age was 74.7 ± 4.1 years and 2836 (47%) were women. AF detection was approximately triple for ILR vs usual care across TSH tertiles (adjusted P interaction = 0.44). In the first tertile, screening was associated with decreased risk of the primary outcome (hazard ratio [HR] 0.52, 95% CI 0.30-0.90; P = .02) and stroke, SE, or cardiovascular death (HR 0.54, 95% CI 0.34-0.84; P = .006) compared with usual care, while no effect was observed among participants with higher TSH (adjusted P interaction .03 and .01, respectively). There was no effect on other outcomes. Analyses of continuous TSH or excluding those with abnormal TSH or thyroid medication showed similar results.

CONCLUSION

AF screening and subsequent treatment was associated with decreased stroke risk among participants with low TSH, though the yield of screening was similar across TSH levels. TSH may be useful as a marker to indicate benefit from AF screening vs overdiagnosis and overtreatment. These findings should be considered exploratory and warrant further study.

Hypertension and Atrial Fibrillation: A Frontier Review From the AF-SCREEN International Collaboration

Hypertension is the leading modifiable risk factor for atrial fibrillation (AF) and is estimated to be present in >70% of AF patients. This Frontiers Review was prepared by 29 expert members of the AF-SCREEN International Collaboration to summarize existing evidence and knowledge gaps on links between hypertension, AF, and their cardiovascular sequelae; simultaneous screening for hypertension and AF; and the prevention of AF through antihypertensive therapy. Hypertension and AF are inextricably connected. Both are easily diagnosed, often silent, and frequently treated inadequately. Together, they additively increase the risk of ischemic stroke, heart failure, and many types of dementia, resulting in greater all-cause mortality, considerable disease burden, and increased health care expenditures. Automated upper arm cuff blood pressure devices with implemented technology can be used to simultaneously detect both hypertension and AF. However, positive screening for AF with an oscillometric blood pressure monitor still requires ECG confirmation. The current evidence suggests that high-risk individuals aged ≥65 years or with treatment-resistant hypertension could benefit from AF screening. Since antihypertensive therapy effectively lowers AF risk, particularly in individuals with left ventricular dysfunction, hypertension should be the key target for AF prediction and prevention rather than merely a comorbidity of AF. Nevertheless, several important gaps in knowledge need to be filled over the next years, including the ideal method and selection of patients for simultaneous screening of hypertension and AF and the optimal antihypertensive drug class and blood pressure targets for AF prevention.

Implantable cardiac monitor in heart failure: just a toy or a useful tool?

The use of implantable cardiac monitors (ICMs) has gradually entered clinical practice in various fields. In addition to the consolidated indications in the study of syncope, cryptogenic stroke and in the management of patients with arrhythmias (suspected or defined), today a possible role for these devices in patients with heart failure (HF) is emerging. The rationale for the use of these devices in HF can be identified in three key areas: (i) identification of silent atrial fibrillation and reduction of the risk of stroke, (ii) stratification of the risk of brady-tachy arrhythmias and consequent reduction of the risk of sudden death, and (iii) identification of patients at risk of imminent exacerbation of HF and their early management with reduction of hospitalizations and episodes of clinical deterioration. For each of these areas, there are conflicting data regarding the real usefulness of ICMs; however, it is reasonable to hypothesize that the use of these devices, under certain conditions, may be useful in patients with HF. The adequate selection of patients to be candidates for this strategy is important. The choice of tools and the availability of an organization that allows the possibility of managing these patients remotely also play an essential role. In any case, case-control studies are needed to establish whether this tool can be truly useful in HF.

Heart failure with preserved ejection fraction and atrial fibrillation: epidemiology, pathophysiology, and diagnosis interplay

Heart failure with preserved ejection fraction (HFpEF) and atrial fibrillation (AF) are increasingly prevalent cardiovascular conditions, particularly among the elderly population. These two conditions share common risk factors and often coexist, leading to a complex interplay that alters the clinical course of each other. The pathophysiology of HFpEF is multifaceted and intricately linked, with atrial disease serving as a common pathophysiological pathway. Diagnosis of HFpEF in the setting of AF, and vice versa, can be challenging; thus, effective screening and diagnostic strategies are needed. Understanding the complex relationship between HFpEF and AF is crucial for optimal patient management by timely disease recognition and identification of therapeutic interventions or treatment strategies.

Association between NT-proBNP levels and risk of atrial fibrillation: a systematic review and meta-analysis of cohort studies

BACKGROUND AND AIMS

N-terminal pro-B-type natriuretic peptide (NT-proBNP) is a well-established biomarker in clinical practice, particularly for heart failure, but its role in predicting atrial fibrillation (AF) risk is not fully understood. This meta-analysis aimed to evaluate the association between NT-proBNP levels and AF incidence, and to explore the potential of NT-proBNP in enhancing AF risk prediction models.

METHODS

We systematically searched databases (PubMed, Embase, Cochrane Library, Web of Science and Scopus) up to August 2024 for prospective studies that reported associations between baseline NT-proBNP levels and incident AF. HRs or relative risks (RRs) with 95% CIs were pooled using random-effects models.

RESULTS

This analysis included 136 089 participants from 16 cohorts, with 8017 incident AF cases. Elevated NT-proBNP levels were associated with a higher risk of developing AF (top vs bottom quartile, RR=3.84, 95% CI 3.03 to 4.87; per SD increment, RR=1.70, 95% CI 1.54 to 1.88). A significant non-linear dose-response relationship was observed (Pnon-linearity<0.05), and stronger associations were noted in older populations and when serum samples were used. Adding NT-proBNP to traditional AF risk models improved predictive accuracy, suggesting its value in AF risk stratification.

CONCLUSIONS

NT-proBNP levels are strongly associated with an increased risk of AF, particularly in older adults. Incorporating NT-proBNP into risk prediction models may enhance early identification of individuals at risk of AF, with potential implications for population-based screening.

PROSPERO REGISTRATION NUMBER

CRD42024538714.

Biomarkers for predicting atrial fibrillation: An explorative sub-analysis of the randomised SCREEN-AF trial

BACKGROUND

Atrial fibrillation (AF) is a common treatable risk factor for stroke. Screening for paroxysmal AF in general practice is difficult, but biomarkers might help improve screening strategies.

OBJECTIVES

We investigated six blood biomarkers for predicting paroxysmal AF in general practice.

METHODS

This was a pre-specified sub-study of the SCREEN-AF RCT done in Germany. Between 12/2017-03/2019, we enrolled ambulatory individuals aged 75 years or older with a history of hypertension but without known AF. Participants in the intervention group received active AF screening with a wearable patch, continuous ECG monitoring for 2x2 weeks and usual care in the control group. The primary endpoint was ECG-confirmed AF within six months after randomisation. High-sensitive Troponin I (hsTnI), brain natriuretic peptide (BNP), N-terminal pro-B-type natriuretic peptide (NT-pro BNP), N-terminal pro atrial natriuretic peptide (NT-ANP), mid-regional pro atrial natriuretic peptide (MR-pro ANP) and C-reactive protein (CRP) plasma levels were investigated at randomisation for predicting AF within six months after randomisation.

RESULTS

Blood samples were available for 291 of 301 (96.7%) participants, including 8 with AF (3%). Five biomarkers showed higher median results in AF-patients: BNP 78 vs. 41 ng/L (p = 0.012), NT-pro BNP 273 vs. 186 ng/L (p = 0.029), NT-proANP 4.4 vs. 3.5 nmol/L (p = 0.027), MR-pro ANP 164 vs. 125 pmol/L (p = 0.016) and hsTnI 7.4 vs. 3.9 ng/L (p = 0.012). CRP levels were not different between groups (2.8 vs 1.9 mg/L, p = 0.1706).

CONCLUSION

Natriuretic peptide levels and hsTnI are higher in patients with AF than without and may help select patients for AF screening, but larger trials are needed.

Integrative proteomic analyses across common cardiac diseases yield mechanistic insights and enhanced prediction

Cardiac diseases represent common highly morbid conditions for which molecular mechanisms remain incompletely understood. Here we report the analysis of 1,459 protein measurements in 44,313 UK Biobank participants to characterize the circulating proteome associated with incident coronary artery disease, heart failure, atrial fibrillation and aortic stenosis. Multivariable-adjusted Cox regression identified 820 protein-disease associations-including 441 proteins-at Bonferroni-adjusted P < 8.6 × 10-6. Cis-Mendelian randomization suggested causal roles aligning with epidemiological findings for 4% of proteins identified in primary analyses, prioritizing therapeutic targets across cardiac diseases (for example, spondin-1 for atrial fibrillation and the Kunitz-type protease inhibitor 1 for coronary artery disease). Interaction analyses identified seven protein-disease associations that differed Bonferroni-significantly by sex. Models incorporating proteomic data (versus clinical risk factors alone) improved prediction for coronary artery disease, heart failure and atrial fibrillation. These results lay a foundation for future investigations to uncover disease mechanisms and assess the utility of protein-based prevention strategies for cardiac diseases.

The role of NT-proBNP in screening for atrial fibrillation in hypertensive disease

Background

Atrial fibrillation (AF) screening should be considered in elderly patients with high risk of stroke, which include individuals with hypertension. The biomarker N-terminal prohormone of brain natriuretic peptide (NT-proBNP) can predict incident AF and is increased in hypertensive individuals. The aim of this study is to investigate the incidence of screening-detected AF in elderly individuals in relation to NT-proBNP and hypertension.

Methods

STROKESTOP II is a randomized controlled trial in which 75/76-years-old individuals were invited to a screening study for AF using NT-proBNP as a discriminator of high risk. In this sub-study, a prior hypertension diagnosis was self-reported by participants and measured blood pressure was stratified into hypertension-grades. Individuals with both increased blood pressure (≥140 mmHg) and NT-proBNP ≥ 125 ng/L were defined as a high-risk group. The lowest risk-group was defined as normotensive participants with NT-proBNP < 125 ng/L.

Results

NT-proBNP increased gradually for every hypertension-grade above hypertension-grade 1 compared to normotensive participants. Screening-detected AF was most common in normotensive participants with increased NT-proBNP (n = 90/1922, 4.7 %), followed by patients with both NT-proBNP > 125 ng/l and SBP ≥ 140 mmHg, (AF = 65/1741, 3.7 %) compared to the low-risk group (AF = 2/1444, 0.1 %), p < 0.001.

Conclusion

NT-proBNP is elevated in elderly patients with hypertension and increases with grades of hypertensive disease. NT-proBNP is a strong predictor of AF regardless of high blood pressure, and the risk for screening-detected AF is very low in participants with normal blood pressure and low NT-proBNP. A combination of blood pressure and NT-proBNP could identify suitable participants for AF screening.

Natriuretic Peptides to Classify Risk of Atrial Fibrillation Detection After Stroke: Analysis of the BIOSIGNAL and PRECISE Cohort Studies

BACKGROUND AND OBJECTIVES

Prolonged cardiac monitoring (PCM) increases atrial fibrillation (AF) detection after ischemic stroke, but access is limited, and it is burdensome for patients. Our objective was to assess whether midregional proatrial natriuretic peptide (MR-proANP) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) could classify people who are unlikely to have AF after ischemic stroke and allow better targeting of PCM.

METHODS

We analyzed people from the Biomarker Signature of Stroke Aetiology (BIOSIGNAL) study with ischemic stroke, no known AF, and ≥3 days cardiac monitoring. External validation was performed in the Preventing Recurrent Cardioembolic Stroke: Right Approach, Right Patient (PRECISE) study of 28 days of cardiac monitoring in people with ischemic stroke or transient ischemic attack and no known AF. The main outcome is no AF detection. We assessed the discriminatory value of MR-proANP and NT-proBNP combined with clinical variables to identify people with no AF. A decision curve analysis was performed with combined data to determine the net reduction in people who would undergo PCM using the models based on a 15% threshold probability for AF detection.

RESULTS

We included 621 people from the BIOSIGNAL study. The clinical multivariable prediction model included age, NIH Stroke Scale score, lipid-lowering therapy, creatinine, and smoking status. The area under the receiver-operating characteristic curve (AUROC) for clinical variables was 0.68 (95% CI 0.62-0.74), which improved with the addition of log10MR-proANP (0.72, 0.66-0.78; p = 0.001) or log10NT-proBNP (0.71, 0.65-0.77; p = 0.009). Performance was similar for the models with log10MR-proANP vs log10NT-proBNP (p = 0.28). In 239 people from the PRECISE study, the AUROC for clinical variables was 0.68 (0.59-0.76), which improved with the addition of log10NT-proBNP (0.73, 0.65-0.82; p < 0.001) or log10MR-proANP (0.79, 0.72-0.86; p < 0.001). Performance was better for the model with log10MR-proANP vs log10NT-proBNP (p = 0.03). The models could reduce the number of people who would undergo PCM by 30% (clinical and log10MR-proANP), 27% (clinical and log10NT-proBNP), or 20% (clinical only).

DISCUSSION

MR-proANP and NT-proBNP help classify people who are unlikely to have AF after ischemic stroke. Measuring MR-proANP or NT-proBNP could reduce the number of people who need PCM by 30%, without reducing the amount of AF detected.

TRIAL REGISTRATION INFORMATION

NCT02274727; clinicaltrials.gov/study/NCT02274727.

Screening for atrial fibrillation: the role of CHA2DS2-VASc and atrial fibrillation burden

Individuals with subclinical atrial fibrillation (AF) face an increased risk of thromboembolic events, which may potentially be mitigated through AF screening and subsequent anticoagulation. However, data from randomized clinical trials (RCTs) indicate a lower stroke risk in subclinical AF compared with the clinical phenotype. This-along with the inherent bleeding risk related to anticoagulation-seems to render the net clinical benefit of AF screening less evident. Further, current guidelines recommend consideration of CHA2DS2-VASc score and AF episode duration to guide screening and treatment. These recommendations, in general, lack support and seem questionable in view of the limited RCT data. More evidence is warranted to provide insights into the potential benefits of screening and treatment of screen-detected AF in specific population subgroups and AF phenotypes.

Diagnostic Utility of N-Terminal Pro-B-Type Natriuretic Peptide in Identifying Atrial Fibrillation Post-Cryptogenic Stroke: A Systematic Review and Meta-Analysis

BACKGROUND

Atrial fibrillation (AF) significantly contributes to acute ischemic stroke, with undetected AF being a common culprit in cryptogenic strokes. N-terminal pro-B-type natriuretic peptide (NT-proBNP), indicative of myocardial stress, has been proposed as a biomarker for AF detection, aiding in the selection of patients for extended cardiac monitoring. However, the diagnostic accuracy of NT-proBNP remains uncertain.

METHODS

We conducted a meta-analysis to evaluate the diagnostic accuracy of NT-proBNP in detecting AF among cryptogenic stroke patients. A comprehensive literature search was conducted across PubMed, Embase, and Cochrane databases to identify relevant studies. Studies reporting NT-proBNP levels in stroke patients and data on the proportion of patients with AF above a specified cut-off were included. Meta-analyses were performed using the midas command in STATA.

RESULTS

Seven studies encompassing 2171 patients were included in the analysis, of which five studies contained cohorts with cryptogenic strokes. Among patients with cryptogenic stroke, NT-proBNP demonstrated a diagnostic accuracy of 80% (Area Under the Receiver Operating Curve 0.80 [95% CI 0.76-0.83]), with a sensitivity of 81% (95% CI 0.68-0.89) and a specificity of 68% (95% CI 0.60-0.75).

CONCLUSION

Our meta-analysis indicates that NT-proBNP exhibits a good-to-very-good diagnostic accuracy for detecting AF in patients with cryptogenic stroke. These findings suggest potential implications for utilizing NT-proBNP in guiding the selection of patients for prolonged cardiac monitoring, thereby aiding in the management of cryptogenic stroke cases.

Interaction of genetic risk and lifestyle on the incidence of atrial fibrillation

BACKGROUND

The relationship between combined genetic predisposition and lifestyle and the risk of incident atrial fibrillation (AF) is unclear. Therefore, we aimed to assess a possible interaction between lifestyle and genetics on AF risk.

METHODS

We included AF cases and a randomly drawn subcohort of 4040 participants from the Danish Diet, Cancer and Health cohort. Lifestyle risk factors were assessed, a score was calculated, and participants were categorised as having a poor, intermediate, or ideal lifestyle. We calculated a genetic risk score comprising 142 variants, and categorised participants into low (quintile 1), intermediate (quintiles 2-4) or high (quintile 5) genetic risk of AF.

RESULTS

3094 AF cases occurred during a median follow-up of 12.9 years. Regardless of genetic risk, incidence rates per 1000 person-years were gradually higher with worse lifestyle. For participants with high genetic risk, the incidence rates of AF per 1000 person-years were 5.0 (95% CI 3.4 to 7.3) among individuals with ideal lifestyle, 6.6 (95% CI 5.4 to 8.1) among those with intermediate lifestyle and 10.4 (95% CI 9.2 to 11.8) among participants with poor lifestyle. On an additive scale, there was a positive statistically significant interaction between genetic risk and lifestyle (relative excess risk due to interaction=0.86, 95% CI 0.68 to 1.03, p<0.001).

CONCLUSIONS

The rates of AF increased gradually with worse lifestyle within each category of genetic risk. We found a positive interaction on an additive scale between genetic risk and lifestyle, suggesting that risk factor modification is especially important in individuals with a high genetic risk of AF.

Association of Device-Detected Atrial High-Rate Episodes With Long-term Cardiovascular and All-Cause Mortality: A Cohort Study

BACKGROUND

Device-detected atrial high-rate episodes (AHREs) were associated with an increased thromboembolic risk. Although limited data regarding the long-term prognosis of patients with AHRE were controversial, this study aimed to identify the association of device-detected AHRE with mortality.

METHODS

This observational study included patients with implantable cardioverter defibrillator (ICD) or cardiac resynchronization therapy defibrillator (CRT-D) placement and no history of atrial fibrillation (AF), atrial flutter (AFL), or atrial tachycardia (AT). During follow-up, patients with at least 1 day of AHRE duration ≥ 15 minutes were identified. The primary endpoint was cardiovascular mortality, and the secondary endpoint was all-cause mortality.

RESULTS

During a mean follow-up period of 4.2 years, AHREs were detected in 124 of 343 (36.2%) patients. Of these, 44 deaths (35.5%) occurred in 124 patients with AHREs, which was significantly higher than those without AHREs (43 of 219; 19.6%; P = 0.001). The multivariate analysis revealed that patients with AHRE had a significantly higher risk of cardiovascular (hazard ratio [HR], 2.40; 95% confidence interval [CI], 1.23-4.67; P = 0.010), and all-cause mortality (HR, 2.31; 95% CI, 1.49-3.59; P < 0.001). Further analysis indicated that this association remained significant in patients with higher burden (≥ 6 hours) but not in patients with lower burden (≥ 15 minutes to 6 hours). Notably, even after excluding the patients diagnosed with clinical AF during follow-up, the remaining patients with AHREs still exhibited a higher risk of cardiovascular and all-cause mortality compared with patients without AHREs.

CONCLUSIONS

AHREs were prevalent in ICD or CRT-D recipients with no history of clinical AF, AFL, or AT and were associated with more than twice the risk of cardiovascular and all-cause mortality.

CLINICAL TRIAL REGISTRATION

No. ChiCTR-ONRC-13003695.

The ABC-Stroke Risk Score and Effects of Atrial Fibrillation Screening on Stroke Prevention: Results From the Randomized LOOP Study

BACKGROUND

The ABC-stroke score is a risk scheme for prediction of stroke or systemic embolism (SE) in atrial fibrillation (AF). This study sought to examine whether the score could be useful in predicting stroke in AF-naïve individuals and risk stratifying for AF screening.

METHODS AND RESULTS

The LOOP (Atrial Fibrillation Detected by Continuous ECG Monitoring Using Implantable Loop Recorder to Prevent Stroke in High-Risk Individuals) study randomized 6004 AF-naïve individuals aged 70 to 90 years with stroke risk factors to either screening with an implantable loop recorder and anticoagulation upon detection of new-onset AF episodes ≥6 minutes, or usual care. A total of 5781 participants had available ABC-stroke score at baseline and were included in this secondary analysis: 4170 (72.1%) with an estimated stroke/SE risk ≤1%/year versus 1611 (27.9%) with an estimated stroke/SE risk >1%/year. Having an annual ABC-stroke risk >1% was associated with stroke/SE, stroke/SE/cardiovascular death, and all-cause death (hazard ratio, 1.82 [95% CI, 1.44-2.21], 2.17 [95% CI, 1.80-2.62], and 2.19 [95% CI, 1.87-2.56], respectively). For screening with implantable loop recorder versus usual care, no significant reduction in these study outcomes was obtained in any ABC-stroke risk groups (P>0.0500 for all), with no signal toward interaction (Pinteraction>0.2500 for all). Similar findings were yielded when assessing the ABC-stroke score as a continuous variable.

CONCLUSIONS

In an elderly, AF-naïve population with additional stroke risk factors, a higher ABC-stroke score could identify individuals with increased stroke risk. However, this risk score may not be useful in pinpointing those more likely to benefit from AF screening and subsequent preventive treatment. These findings should be considered as hypothesis generating and warrant further study.

REGISTRATION

URL: https://www.clinicaltrials.gov; unique identifier: NCT02036450.

Diagnostic yield of a proactive strategy for early detection of cardiovascular disease versus usual care in adults with type 2 diabetes or chronic obstructive pulmonary disease in primary care in the Netherlands (RED-CVD): a multicentre, pragmatic, cluster-randomised, controlled trial

BACKGROUND

Progressive cardiovascular diseases (eg, heart failure, atrial fibrillation, and coronary artery disease) are often diagnosed late in high-risk individuals with common comorbidities that might mimic or mask symptoms, such as chronic obstructive pulmonary disease (COPD) and type 2 diabetes. We aimed to assess whether a proactive diagnostic strategy consisting of a symptom and risk factor questionnaire and low-cost and accessible tests could increase diagnosis of progressive cardiovascular diseases in patients with COPD or type 2 diabetes in primary care.

METHODS

In this multicentre, pragmatic, cluster-randomised, controlled trial (RED-CVD), 25 primary care practices in the Netherlands were randomly assigned to usual care or a proactive diagnostic strategy conducted during routine consultations and consisting of a validated symptom questionnaire, followed by physical examination, N-terminal-pro-B-type natriuretic peptide measurement, and electrocardiography. We included adults (≥18 years) with type 2 diabetes, COPD, or both, who participated in a disease management programme. Patients with an established triple diagnosis of heart failure, atrial fibrillation, and coronary artery disease were excluded. In the case of abnormal findings, further work-up or treatment was done at the discretion of the general practitioner. The primary endpoint was the number of newly diagnosed cases of heart failure, atrial fibrillation, and coronary artery disease, adjudicated by an expert clinical outcome committee using international guidelines, at 1-year follow-up, in the intention-to-treat population.

FINDINGS

Between Jan 31, 2019, and Oct 7, 2021, we randomly assigned 25 primary care centres: 11 to usual care and 14 to the intervention. We included patients between June 21, 2019, and Jan 31, 2022. Following exclusion of ineligible patients and those who did not give informed consent, 1216 participants were included: 624 (51%) in the intervention group and 592 (49%) in the usual care group. The mean age of participants was 68·4 years (SD 9·4), 482 (40%) participants were female, and 734 (60%) were male. During 1 year of follow-up, 50 (8%) of 624 participants in the intervention group and 18 (3%) of 592 in the control group were newly diagnosed with heart failure, atrial fibrillation, or coronary artery disease (adjusted odds ratio 2·97 [95% CI 1·66-5·33]). This trial is registered with the Netherlands Trial Registry, NTR7360, and was completed on Jan 31, 2023.

INTERPRETATION

An easy-to-use, proactive, diagnostic strategy more than doubled the number of new diagnoses of heart failure, atrial fibrillation, and coronary artery disease in patients with type 2 diabetes or COPD in primary care compared with usual care. Although the effect on patient outcomes remains to be studied, our diagnostic strategy might contribute to improved early detection and timely initiation of treatment in individuals with cardiovascular disease.

FUNDING

Dutch Heart Foundation.

Integrative proteomic analyses across common cardiac diseases yield new mechanistic insights and enhanced prediction

Cardiac diseases represent common highly morbid conditions for which underlying molecular mechanisms remain incompletely understood. Here, we leveraged 1,459 protein measurements in 44,313 UK Biobank participants to characterize the circulating proteome associated with incident coronary artery disease, heart failure, atrial fibrillation, and aortic stenosis. Multivariable-adjusted Cox regression identified 820 protein-disease associations-including 441 proteins-at Bonferroni-adjusted P <8.6×10 -6 . Cis -Mendelian randomization suggested causal roles that aligned with epidemiological findings for 6% of proteins identified in primary analyses, prioritizing novel therapeutic targets for different cardiac diseases (e.g., interleukin-4 receptor for heart failure and spondin-1 for atrial fibrillation). Interaction analyses identified seven protein-disease associations that differed Bonferroni-significantly by sex. Models incorporating proteomic data (vs. clinical risk factors alone) improved prediction for coronary artery disease, heart failure, and atrial fibrillation. These results lay a foundation for future investigations to uncover novel disease mechanisms and assess the clinical utility of protein-based prevention strategies for cardiac diseases.