NEW YORK (Reuters Health) – Therapy aimed at reducing levels of amino-terminal pro–B-type natriuretic peptide (NT-proBNP) in patients with chronic heart failure (HF) is more beneficial than standard treatment, a Boston team reports in the October 25th issue of the Journal of the American College of Cardiology.
“If confirmed, the addition of natriuretic peptide–guided therapy to standard care may represent a new paradigm for HF practice,” conclude Dr. James L. Januzzi, Jr, and colleagues at Massachusetts General Hospital.
In their paper, they note that high or rising levels of natriuretic peptides predict adverse outcomes in chronic heart failure, but results have been mixed in trials examining the benefit of attempting to lower NT-proBNP levels.
To clarify the situation, the investigators randomized 151 patients with heart failure due to left ventricular systolic dysfunction (LVSD) to standard-of-care management or to standard care plus treatment aimed at reducing NT-proBNP concentrations to less than 1000 pg/mL. This goal involved intensifying drug therapy or reassessing the treatment regimen, regardless of “clinical status or perception of the presence of an optimal medical program.”
The primary endpoint was total cardiovascular events, a composite of worsening HF, hospitalization for HF, clinically significant ventricular arrhythmia, acute coronary syndromes, cerebral ischemia, or cardiac death.
Over a mean follow-up of 10 months, 100 cardiovascular events occurred the standard care group compared with 58 in the NT-proBNP-guided arm (odds ratio 0.44; p=0.02), Dr. Januzzi and colleagues report.
Furthermore, the NT-proBNP group had greater improvements than the standard group in secondary measures such as quality of life (-10 vs -5; p=0.05), absolute LV ejection fraction (8.3% vs. 4.0%; p=0.06), and in both LV end-systolic and end-diastolic volume indexes.
There was no significant difference in serious adverse events between treatment arms, the report indicates.
Summing up, the researchers conclude, “Our results thus suggest that in patients with HF due to LVSD, NTproBNP monitoring with aggressive care to lower concentrations below a threshold value may be a useful tool to assist in standard HF care.”
In an accompanying editorial, Dr. Alan Maisel with the VA San Diego Healthcare System, California, reviews the use of biomarkers to guide HF treatment. He suggests that natriuretic peptides are nearly ideal for this purpose but others will follow, and “may lead to a better segmentation of the HF syndrome into individual phenotypes (so-called pharmacophenomics) on the basis of the likelihood of response to specific therapies.”
Reference:
J Am Coll Cardiol 2011;58:1881–1889.
