Dual-Biomarker Navigation Clinic (NT-proBNP + hs-Troponin) Accelerates GDMT Up-Titration and Lowers 6-Month Events in HFrEF/HFmrEF: A Pragmatic Program from Oman

Abstract

Background & Purpose: Single-biomarker follow-up can miss actionable risk in heart failure (HF). We implemented a Dual-Biomarker Navigation Clinic (DBNC) using point-of-care NT-proBNP and hs-troponin to trigger same-day guideline-directed medical therapy (GDMT) up-titration with pharmacist follow-up.

Methods: Prospective cohort with 1:1 propensity-matched usual-care controls. Inclusion: symptomatic HFrEF/HFmrEF (LVEF ≤50%), outpatient NT-proBNP ≥600 pg/mL or rising ≥30% within 3 months. DBNC protocol: POC NT-proBNP + hs-cTn at visit; algorithmic triggers for ARNI/SGLT2i/MRA/β-blocker up-titration; WhatsApp reminders; nurse calls at 2 and 4 weeks. Primary endpoint: 6-month composite (HF hospitalization or all-cause death). Secondary: achieving ≥½-target doses by 90 days, adherence (proportion of days covered [PDC] ≥80% at 90 days), biomarker % change at ~90 days. Adjusted Cox/logistic models controlled for age, sex, EF, eGFR, NYHA class, ischemic etiology.

Results: n=404 (DBNC 202; matched usual care 202), age 62±11, 35% female, LVEF 34±8%. By 90 days, DBNC vs usual care: ARNI ≥½-target 56% vs 34% (aOR 2.55, 95%CI 1.72–3.80); β-blocker ≥½-target 69% vs 50% (aOR 2.12, 1.43–3.15); MRA ≥½-target 61% vs 45% (aOR 1.92, 1.28–2.89); PDC ≥80% 66% vs 52% (aOR 1.76, 1.19–2.61). Biomarkers: NT-proBNP −29% vs −18% (p=0.012); hs-cTn −8% vs −2% (p=0.045). The 6-month composite occurred in 17% vs 25%; adjusted HR 0.68 (95%CI 0.48–0.96; p=0.028). Hypotension (5.0% vs 5.4%) and AKI KDIGO≥2 (3.7% vs 3.5%) were similar.

Conclusions: A pragmatic dual-biomarker clinic tied to immediate, protocolized titration accelerated GDMT, improved adherence, reduced NT-proBNP and hs-troponin, and lowered 6-month events without added safety risk. This model is implementable in regional HF services without sST2 availability.