A year-end #Tweetorial for #MedTwitter about serial biomarker testing for clinical evaluation of patients with #HeartFailure.

The use of serial #NTproBNP testing, often at every office visit has grown.

New data are available that emphasize the importance. Read on 👇 In a just-published analysis, colleagues from the GUIDE-IT Trial team examined the prognostic meaning of a single versus serial assessment of NT-proBNP among individuals with chronic #HFrEF.

jacc.org/doi/10.1016/j.…

Day 6 on service at @MGHHeartHealth and we're running on fumes. But Thanksgiving is just around the corner, so all is well.

At the request of Dr. @CoronaryDoc, a thread on appropriate use of natriuretic peptides.

There's a time to measure them. And a time not to. Just a reminder of NP biology:

NP genes are highly conserved across species. Your ANP is only one amino acid different than the ANP of a rat, for example.

In addition to being conserved across species, the three CV NPs (ANP, BNP, CNP) have structural similarities.

Day 5 on service at @MGHHeartHealth. No better time than now to think about the favorite drug of @AndrewJSauer...spironolactone.

The story of how the drug was discovered is interesting, and gave a hint as to the fact the drug would eventually become a pillar of HF care. The first mineralocorticoid synthesized was deoxycorticosterone (DOC). Simultaneously, aldosterone was discovered. Both exerted powerful sodium retention effects. This was in the early 1950s.

Simultaneously, people began to recognize that pts with HF retained salt and water...

Day 4 on service @MGHHeartHealth. 4 thoughts on beta blockers.

Don’t worry @AndrewJSauer, MRA are coming tomorrow.

@cardiojaydoc02 @AHajduczok One: begin your target BB at the start. I don’t know how the culture of starting short acting metoprolol “for titration” came from but it’s not supported by any science, uses a drug that failed in the MDC trial, and may actually be harder to titrate due to on/off effects.

Here's a question that you might not have considered: how did the dose for #sacubitril/valsartan in #HFrEF get chosen?

Out today is a paper in @JACCJournals led by @RezaMohebiMD that addresses some questions about sac/val dose in HFrEF.

a 🧵

jacc.org/doi/epdf/10.10… It's a little known fact that prior to the PH3 PARADIGM trial, a PH2 study in HFrEF was not performed--normally PH2 studies provide target doses for the pivotal outcomes trials.

So how was the dose of sacubitril/valsartan chosen??

Presented today as late-breaking data at #HFSA2022 and posted online @CircAHA, new data from PROVE-HF regarding impact of #sacubitril/valsartan on #mitralregurgitation in #HFrEF.

Thanks to @DukeHFDoc for presenting in my absence.

What did we find? A 🧵... It is well-known that MR severity is an important determinant of symptoms and prognosis in those with HFrEF.

Thanks to work from @LindenfeldJoann and @GreggWStone in the COAPT trial, it is also known that repair of MR may improve outcome in HFrEF.

What happens to BNP when a person is started on #sacubitrilvalsartan?

#BNP should go up, right?

Thanks to work by @pmyhre in our group, we have some new and interesting data.

A 🧵, read on! 👇 When the #PARADIGM-HF study was published, one of the things immediately noticed was the increase in BNP that occurred after being started on sacubitril/valsartan.

This is because through effect of sacubitril, neprilysin is inhibited. Why might this lead to an increase in BNP?

In one month, I've diagnosed more cases of ATTR cardiomyopathy than I did in 10 years. If you don't look for it, you won't find it.

A micro-tweetorial...

What should you look for?

@HannaGaggin @frederickruberg --unexplained mild "LVH"
--PAF that has little explanation
--spinal stenosis
--carpal tunnel
--orthostatic hypotension
--bruising
--lack of EF response to #GDMTworks
--Diuretic sensitivity
--Higher biomarkers "than they should be"

A tweetorial.

Here's an intriguing analysis just published in Diabetes Care by the great folks at @AmDiabetesAssn and @ADA_Journals. We examined concentrations of insulin-like growth factor binding protein-7 (IGFBP7) at BL and 1Y in the CANVAS study.

care.diabetesjournals.org/content/early/…

1/ Why IGFBP7? Good question.

Though IGFBP7 "looks like" an IGF binder, it is lousy at this job. But IGFBP7 has other roles: it is a cell cycle arrest biomarker in the 'senescence associated secretory phenotype'.

When cells are exposed to IGFBP7 in excess, fibrosis follows.

2/

I just finished reading another poorly-composed position paper from a major society regarding COVID19 with recommendations based on a handful of sometimes questionable papers and have a few thoughts. 1) The pandemic has put a terrible strain on everyone. It's been very, very difficult and very frightening. What some institutions went through will leave them scarred for years to come. All of this has left people hungry for high quality science informing treatment decisions. 2)

Breaking habits in medicine can be hard. Case in point: "trending troponin to peak" in patients with MI. Why is this done? Is it useful? You might be surprised at the answer. 1/ @NinoNJ @CianPMcCarthy @MGHMedicine @MGHHMU @MGHHeartHealth @chapdoc1 @HighSTEACS @troponinpapers 2/Why "trend troponin to peak" anyhow? Most do it to "size" the infarct; specifically, the concept is that the amount of troponin efflux from necrotic tissue is proportional to the size of the infarct.

But is this true? Is it accurate?