In the Journals

Achieved BNP goals linked to better outcomes for acute decompensated HF

Among patients hospitalized with acute decompensated HF, attainment of absolute brain natriuretic peptide thresholds appears to be correlated with decreased acute decompensated HF deaths and readmissions, according to recent findings.

In the systematic review, researchers identified studies published from 1947 to October 2016 that assessed the relationship between a goal-oriented strategy for tracking decongestion in acute decompensated HF and patient-centered outcomes. Studies included in the analysis reported data on adult patients hospitalized for acute decompensated HF and treated with diuretics in an acute setting.

The following types of studies were included: randomized controlled trials, cohort studies, case-control studies and quasi-experimental studies.

One randomized trial, three quasi-experimental studies and 40 observational studies were selected. Thirty-one studies utilized brain natriuretic peptide (BNP) thresholds; of these, 27 assessed an absolute threshold and nine used a threshold based on percentage reduction. Sixteen studies evaluated mortality, five assessed readmissions and 33 analyzed a composite of these outcomes.

The most frequently used threshold was a BNP level of 250 pg/mL or less. Of 27 studies evaluating absolute thresholds, 15 assessed absolute thresholds at or below 250 pg/mL.

The achievement of a predischarge absolute BNP threshold was significantly associated with decreased mortality rate in seven of eight studies (HR range, 0.08-0.82), hospital readmission in two of three studies (HR range, 0.07-0.97) and the composite outcome in 11 of 13 studies (HR range, 0.07-0.78) that reported HRs.

The attainment of percentage-change BNP thresholds decreased the composite outcome in five of six studies, and attainment of percentage change N-terminal pro-BNP (NT-proBNP) thresholds decreased all-cause and CV deaths in two of four studies and the composite outcome in all of nine studies. The researchers determined that all evidence was low strength.

In the randomized trial, which was determined to have a high risk for bias, the evidence suggested that a decrease in NT-proBNP before discharge was linked to reduced risk for the composite outcome. Low risk for bias was determined in two quasi-experimental studies and five observational studies. The outcome estimates determined in low risk-of-bias studies were comparable in scale and direction to high risk-of-bias studies.

“The quality of the current body of literature is inadequate to fully assess whether discharge thresholds can be prospectively used to improve clinical outcomes,” the researchers wrote. “Future, carefully designed randomized controlled trials must use clear algorithmic methods to guide diuresis, consider important confounders of NP levels, test achievable predischarge thresholds … and analyze data for both short- and long-term follow-up to address this important clinical question.” by Jennifer Byrne

Disclosure: One researcher reports receiving grants from the Institute for Translational Medicine and Therapeutics of the Perelman School of Medicine at the University of Pennsylvania and from the NIH during the conduct of the study. Another researcher reports receiving personal fees from Medtronic and a grant from Respicardia outside the submitted work.

Among patients hospitalized with acute decompensated HF, attainment of absolute brain natriuretic peptide thresholds appears to be correlated with decreased acute decompensated HF deaths and readmissions, according to recent findings.

In the systematic review, researchers identified studies published from 1947 to October 2016 that assessed the relationship between a goal-oriented strategy for tracking decongestion in acute decompensated HF and patient-centered outcomes. Studies included in the analysis reported data on adult patients hospitalized for acute decompensated HF and treated with diuretics in an acute setting.

The following types of studies were included: randomized controlled trials, cohort studies, case-control studies and quasi-experimental studies.

One randomized trial, three quasi-experimental studies and 40 observational studies were selected. Thirty-one studies utilized brain natriuretic peptide (BNP) thresholds; of these, 27 assessed an absolute threshold and nine used a threshold based on percentage reduction. Sixteen studies evaluated mortality, five assessed readmissions and 33 analyzed a composite of these outcomes.

The most frequently used threshold was a BNP level of 250 pg/mL or less. Of 27 studies evaluating absolute thresholds, 15 assessed absolute thresholds at or below 250 pg/mL.

The achievement of a predischarge absolute BNP threshold was significantly associated with decreased mortality rate in seven of eight studies (HR range, 0.08-0.82), hospital readmission in two of three studies (HR range, 0.07-0.97) and the composite outcome in 11 of 13 studies (HR range, 0.07-0.78) that reported HRs.

The attainment of percentage-change BNP thresholds decreased the composite outcome in five of six studies, and attainment of percentage change N-terminal pro-BNP (NT-proBNP) thresholds decreased all-cause and CV deaths in two of four studies and the composite outcome in all of nine studies. The researchers determined that all evidence was low strength.

In the randomized trial, which was determined to have a high risk for bias, the evidence suggested that a decrease in NT-proBNP before discharge was linked to reduced risk for the composite outcome. Low risk for bias was determined in two quasi-experimental studies and five observational studies. The outcome estimates determined in low risk-of-bias studies were comparable in scale and direction to high risk-of-bias studies.

“The quality of the current body of literature is inadequate to fully assess whether discharge thresholds can be prospectively used to improve clinical outcomes,” the researchers wrote. “Future, carefully designed randomized controlled trials must use clear algorithmic methods to guide diuresis, consider important confounders of NP levels, test achievable predischarge thresholds … and analyze data for both short- and long-term follow-up to address this important clinical question.” by Jennifer Byrne

Disclosure: One researcher reports receiving grants from the Institute for Translational Medicine and Therapeutics of the Perelman School of Medicine at the University of Pennsylvania and from the NIH during the conduct of the study. Another researcher reports receiving personal fees from Medtronic and a grant from Respicardia outside the submitted work.