Effectiveness of Natriuretic Peptide Guided Therapy for Heart Failure

Angiotensin-converting enzyme inhibitors, angiotensin II receptor antagonists, angiotensin receptor neprilysin inhibitors, β-blockers, and mineralocorticoid receptor antagonists have all been shown to improve outcomes of patients with reduced ejection fraction congestive heart failure. An ongoing question is whether therapy that is guided by a natriuretic peptide target would yield a better outcome than therapy guided by clinical parameters. Previous studies have yielded mixed results. The current 2017 Heart Failure guideline update states, “Because of the absence of clear and consistent evidence for improvement in mortality and cardiovascular outcomes at present there are insufficient data to inform specific guideline recommendations related to natriuretic peptide–guided therapy or serial measurements of BNP or NT-proBNP levels for the purpose of reducing hospitalization or deaths”.

A recently completed randomized clinical trial sheds more light on this controversy. The trial was conducted between January 16, 2013, and September 20, 2016, at 45 clinical sites in the US and Canada. It included 894 adults and compared a strategy of NT-proBNP–guided therapy with usual care for improving time to first hospitalization or cardiovascular mortality. The major findings of this study were:

  • The primary end point of time to first heart failure hospitalization or CV mortality occurred in 164 patients (37%) in the BNP-guided group and in 164 patients (37%) in the usual care group.
  • CV mortality was 12% in the BNP-guided group and 13% in the usual care group.
  • None of the secondary end points nor the decreases in the NT-proBNP levels achieved differed significantly between groups.

This study concluded that a strategy of NT-proBNP-guided therapy was not more effective than usual care in the management of or improving outcomes in high-risk patients with heart failure and reduced ejection fraction.

Felker GM, Anstrom KJ, Adams KF, et al. Effect of natriuretic peptide–guided therapy on hospitalization or cardiovascular mortality in high-risk patients with heart failure and reduced ejection fraction. A randomized clinical trial. JAMA. Aug 22/27, 2017;318(8):713–720. doi:10.1001/jama.2017.10565.

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