Natriuretic peptide-guided therapy in chronic heart failure: a meta-analysis of 2,686 patients in 12 randomized trials

G Savarese,P Perrone Filardi,M Prastaro,D Leosco,G Rengo,B Trimarco,F Gambardella,S Dellegrottaglie

doi:10.1093/eurheartj/eht309.p3326

G Savarese, P Perrone Filardi + Show 6 more

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https://doi.org/10.1093/eurheartj/eht309.p3326

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Abstract

Background: The role of cardiac natriuretic peptides in the management of patients with chronic Heart Failure (HF) remains uncertain. The purpose of this study was to evaluate whether natriuretic peptide-guided therapy, compared to clinically-guided therapy, improves mortality and hospitalization rate in patients with chronic HF. Methods: MEDLINE, Cochrane, ISI Web of Science and SCOPUS databases were searched for articles reporting natriuretic peptide-guided therapy in HF until August 2012. All randomized trials reporting clinical end-points (all-cause mortality and/or HF-related hospitalization and/or all-cause hospitalization) were included. Meta-analysis was performed to assess the influence of treatment on outcomes. Sensitivity analysis was performed to test the influence of potential effect modifiers and of each trial included in meta-analysis on results. Results: Twelve trials enrolling 2,686 participants were included. Natriuretic peptide-guided therapy (either B-type Natriuretic Peptide [BNP]- or N-terminal pro-B-type natriuretic peptide [NT-proBNP]-guided therapy) significantly reduced all-cause mortality (Odds Ratio [OR]:0.738; 95% Confidence Interval [CI]:0.596 to 0.913; p=0.005) and HF-related hospitalization (OR:0.554; CI:0.399 to 0.769; p=0.000), but not all-cause hospitalization (OR:0.803; CI:0.629 to 1.024; p=0.077). When separately assessed, NT-proBNP-guided therapy significantly reduced all-cause mortality (OR:0.717; CI:0.563 to 0.914; p=0.007) and HF-related hospitalization (OR:0.531; CI:0.347 to 0.811; p=0.003), but not all-cause hospitalization (OR:0.779; CI:0.414 to 1.465; p=0.438), whereas BNP-guided therapy did not significantly reduce all-cause mortality (OR:0.814; CI:0.518 to 1.279; p=0.371), HF-related hospitalization (OR:0.599; CI:0.303 to 1.187; p=0.142) or all-cause hospitalization (OR:0.726; CI:0.609 to 0.964; p=0.077). Conclusions: Use of cardiac peptides to guide pharmacologic therapy significantly reduces mortality and HF related hospitalization in patients with chronic HF. In particular, NT-proBNP-guided therapy reduced all-cause mortality and HF-related hospitalization but not all-cause hospitalization, whereas BNP-guided therapy did not significantly reduce both mortality and morbidity.

Highlights

Chronic Heart Failure (HF) represents a raising health care concern in developed and developing countries, reaching epidemic proportions [1]
Natriuretic peptide-guided therapy led to a significant reduction of all-cause mortality (OR: 0.738; 95% Confidence Interval (CI): 0.596 to 0.913; comparison p = 0.005; heterogeneity p = 0.896) without heterogeneity among studies
NT-proBNP-guided therapy significantly reduced all-cause mortality (OR: 0.717; 95% CI: 0.563 to 0.914; comparison p = 0.007; heterogeneity p = 0.692), whereas B-type natriuretic peptide (BNP)-guided therapy did not (OR: 0.814; 95% CI: 0.518 to 1.279; comparison p = 0.371; heterogeneity p = 0.823)

Summary

Introduction

Chronic Heart Failure (HF) represents a raising health care concern in developed and developing countries, reaching epidemic proportions [1]. In recent years progresses of pharmacologic and non-pharmacologic therapies led to substantial improvement of survival and rate of hospitalization in HF patients, prognosis remains poor [2,3,4]. Up-titration of medications in chronic HF remains suboptimal in clinical practice, with administered doses often lower than those utilized in clinical trials, preventing achievement of the full benefit of evidence-based therapies [5,6]. Development of strategies to enhance adherence to guidelines recommended doses of drugs would be much needed to reduce the burden of mortality and morbidity in chronic HF patients. The role of cardiac natriuretic peptides in the management of patients with chronic heart failure (HF) remains uncertain. The purpose of this study was to evaluate whether natriuretic peptide-guided therapy, compared to clinicallyguided therapy, improves mortality and hospitalization rate in patients with chronic HF

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