Troponins may be useful guide for ARNI therapy in HFpEF, finds JACC study

Heart failure (HF) with preserved ejection fraction (HFpEF) accounts for one-half of HF cases, and research has been ongoing for many years to find effective treatment strategies for the same. The prognostic value of high sensitivity troponin-T (hs-TnT) in HFpEF, and whether hs-Tn modifies the treatment response to sacubitril/valsartan, remains uncertain.

In this regard, Gori et al assessed the relationship among hs-TnT, outcomes, and the efficacy of treatment with sacubitril/valsartan in the PARAGON-HF trial and found that higher hs-TnT was associated with increased risk outcomes in HFpEF which were reduced with the use of sacubitril/valsartan compared with valsartan.

In the PARAGON-HF trial, sacubitril/ valsartan resulted in modest reductions in total HF hospitalizations (HHF) and cardiovascular death (CVD) compared with valsartan alone. Since the early studies of high-sensitivity troponins in chronic heart failure with reduced ejection fraction (HFrEF), the predictive value of troponin became increasingly evident.

Gori et al thus aimed to explore the utility of this marker in HFpEF from the PARAGON-HF cohort and compared the risk of the composite outcome of CVD and total HHF according to hs-TnT. They also assessed the effect of allocated treatment on hs-TnT.

The study has provided following important findings:

1. Female sex is strongly associated with lower hsTnT. This trend is not evident for NT-proBNP.

2. Conversely, hsTnT is unaffected by high body mass index while NT-proBNP and BNP concentrations are significantly lower in obese.

3. Sacubitril/valsartan decreased NT-proBNP concentrations over 16 weeks by 19%, while the decrease in hsTnT was 9%.

4. Sacubitril/valsartan reduced circulating NT-proBNP levels to a lesser extent in patients with atrial fibrillation (AF), but the same unexpected trend was not reported for hsTnT.

5. Also, antecedent AF raised NT-proBNP while no such interaction occurred with hsTnT.

6. Consistent with the overall lack of superiority of sacubitril/valsartan versus valsartan in PARAGON-HF, NT-proBNP baseline concentrations did not affect the impact of the study drug.

7. However, sacubitril/valsartan tended to have a greater effect in patients with higher baseline hsTnT than in those with lower baseline hsTnT.

"Altogether, we can conclude that the 2 cardiac biomarkers tell somewhat different stories in HFpEF", mention Latini et al in an accompanying editorial. In other words, a complementary relationship between natriuretic peptides and hsTnT has been confirmed so that the combination of the 2 biomarkers is proposed for identification of patients with HFpEF at high risk.

To conclude, higher baseline hs-TnT was associated with increased risk of CVD/HHF, whereas hs-TnT decrease at 16 weeks led to lower subsequent risk of CVD/HHF compared with those who had persistently elevated values. Sacubitril/ valsartan significantly reduced hs-TnT compared with valsartan. hs-TnT may be helpful in identifying patients with HFpEF who are more likely to benefit from sacubitril/valsartan.

Source: JACC Heart Failure: https://doi.org/10.1016/j.jchf.2021.04.009