Prescreen with Contact Fields

STUDY D7266C00001 · HCP REFERRAL AID

30-Second Heart Failure Prescreen

Use Yes, Unsure, or No. This tool identifies possible referrals; it does not determine study eligibility.

Patient contact

Limited referral information

First name

Last-name initial

Phone number

I confirm that I am authorized to provide this patient's contact information to Valiance Clinical Research for referral follow-up.

1. Basic must haves

Any Yes needs site review

Patient is 18 years or older

Yes Unsure No

Symptomatic heart failure, NYHA class II–IV

Yes Unsure No

Most recent LVEF is greater than 40% with structural heart disease Left ventricular hypertrophy or left atrial enlargement on qualifying imaging.

Yes Unsure No

NT-proBNP meets the likely study threshold At least 300 pg/mL without ongoing AF/flutter or 900 pg/mL with ongoing AF/flutter.

Yes Unsure No

Currently receiving an oral loop or thiazide diuretic

Yes Unsure No

Qualifying body size BMI ≥30, or BMI 25 to <30 with waist-to-height ratio ≥0.5.

Yes Unsure No

2. Quick stop-sign check

ANY YES NEEDS SITE REVIEW

Recent acute cardiovascular event or major procedure At lACS, stroke, or TIA within 3 months; or specified major cardiac procedure within 90 days.

Yes Unsure No

Major diabetes, kidney, liver, or pulmonary concern Type 1/secondary diabetes, HbA1c ≥10%, dialysis/eGFR <20, significant liver disease, or severe pulmonary disease.

Yes Unsure No

Other major potential exclusion Pancreatitis; MTC/MEN2 history; recent GLP-1 therapy; pregnancy/breastfeeding; certain cardiomyopathies; or active malignancy not covered by protocol exceptions.

Yes Unsure No

We’ll keep you updated

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