Sunday, September 10, 2017

Biomarker guided heart failure treatment versus usual (guideline based) care: take your pick!

Question Does a strategy of titrating therapy to a specific amino-terminal pro–B-type natriuretic peptide (NT-proBNP) target improve clinical outcomes in high-risk patients with heart failure and reduced ejection fraction?

Findings In this randomized clinical trial including 894 adults, a strategy of NT-proBNP–guided therapy compared with usual care did not significantly improve time to first hospitalization or cardiovascular mortality (hazard ratio, 0.98).

Meaning These findings do not support NT-proBNP–guided therapy for management of heart failure with reduced ejection fraction.

From table 2 in the paper we learn that both groups got the same treatment. That is, whether you tended to ignore proBNP levels and just do your best to adhere to guidelines or individualized therapy based on proBNP levels, you ended up with the same regimen. These, or course, were trial participants. What would happen in the real world where guideline goal achievement is horrible?

An accompanying editorial summarized what we knew before:

Assays for natriuretic peptide biomarkers, B-type natriuretic peptide (BNP) and N-terminal pro-B-type natriuretic peptide (NT-proBNP), have become well established for assisting with the diagnosis and assessment of the severity of heart failure and for providing prognostic information in both the setting of acute care of decompensated heart failure and outpatient care of chronic heart failure...

..several randomized clinical trials have evaluated whether the application of serial measurement of natriuretic peptide to guide the titration of medical therapy in chronic heart failure could improve outcomes.4,6 Those trials have yielded mixed results.

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