Key Points:
- Tertiary screening for chronic cardiovascular disease as a means to reduce morbidity, mortality, and economic burden on the healthcare system has been proposed.
- RED-CVD trial was the first cluster randomized trial, that investigated the diagnostic yield of a systematic multi-step early screening strategy for an aggregate of coronary artery disease, heart failure, and atrial fibrillation, compared with usual care among high-risk patients.
- Active screening of patients with type 2 diabetes or COPD more than doubles new diagnoses of cardiovascular disease compared with usual care.
Cardiovascular disease (CVD) is the leading cause of morbidity and mortality, with a disproportionately high direct and indirect economic burden. Coronary artery disease (CAD), heart failure (HF), and atrial fibrillation (AF) are the most prevalent cardiovascular diseases affecting millions of people. Early screening for these diseases has been suggested as a means to reduce acute presentations and further clinical decline. However, tertiary screening efforts often target each condition in isolation, despite significant overlap in not only risk factors but also signs and symptoms. Hence, whether a strategy of systematically screening for these conditions in aggregate in a primary care setting among high-risk patients leads to an increased diagnostic yield is unknown.
On Monday, August 28th, 2023, Dr. Amy Groenewegen from the University Medical Centre Utrecht in the Netherlands presented the results of the “Reviving the Early Diagnosis of CVD” or RED-CVD trial in a hotline session at the ESC 2023 Congress in Amsterdam. In this cluster-randomized, pragmatic trial, primary care practices across the Netherlands were randomized to a stepwise diagnostic strategy or usual care. The diagnostic strategy employed was a 3-step process: 1) Patients completed a pre-visit a risk factor and symptom questionnaire before they visited a type 2 diabetes or COPD management program; 2) Patients surpassing a predetermined threshold on the questionnaire received a thorough assessment by the practice nurse during a regular visit including a focused heart failure assessment, 12-lead electrocardiography, and NT-proBNP measurements; 3) General practitioners evaluated the results from steps 1 and 2, determining the need for referral to a cardiologist or open access echocardiography.
The primary efficacy endpoint was a composite of new cases of HF, AF, and CAD one year after the baseline visit. Secondary endpoints assessed the initiation of new treatments within the same timeframe.
Overall, 1,216 patients (624 in the intervention group, 592 in the control group) were included, with an average age of 68 years of whom 40% were women. The prevalence of type 2 diabetes was 87% and COPD was 20% (a few patients had both conditions). At 1 year, the intervention group saw a substantial increase in new diagnoses of CVD compared to the control group (8.0% vs. 3.2%, respectively) driven mainly by a new diagnosis of heart failure (4.5% vs. 1.5%), followed by CAD (2.6% vs.1.4%) and AF (2.1% vs. 1.0%). There were no major differences in medication use observed.
According to study author Dr. Groenewegen: “An easy-to-implement strategy more than doubled the number of new diagnoses of heart failure, atrial fibrillation and coronary artery disease in high-risk patients. Because there are so many adults in the community with COPD or type 2 diabetes, this approach could translate into tens of thousands of new diagnoses when applied at large. In the Netherlands, for example, screening the more than 920,000 patients with COPD and/or type 2 diabetes could identify over 44,000 patients with at least one previously undiagnosed cardiovascular condition.”
