Serial NT-proBNP monitoring and outcomes in outpatients with decompensation of heart failure

Implementation of the Care Bundle for the Management of Chronic Obstructive Pulmonary Disease with/without Heart Failure

Chronic obstructive pulmonary disease (COPD) is often part of a more complex cardiopulmonary disease, especially in older patients. The differential diagnosis of the acute exacerbation of COPD and/or heart failure (HF) in emergency settings is challenging due to their frequent coexistence and symptom overlap. Both conditions have a detrimental impact on each other's prognosis, leading to increased mortality rates. The timely diagnosis and treatment of COPD and coexisting factors like left ventricular overload or HF in inpatient and outpatient care can improve prognosis, quality of life, and long-term outcomes, helping to avoid exacerbations and hospitalization, which increase future exacerbation risk. This work aims to address existing gaps, providing management recommendations for COPD with/without HF, particularly when both conditions coexist. During virtual meetings, a panel of experts (the authors) discussed and reached a consensus on the differential and paired diagnosis of COPD and HF, providing suggestions for risk stratification, accurate diagnosis, and appropriate therapy for inpatients and outpatients. They emphasize that when COPD and HF are concomitant, both conditions should receive adequate treatment and that recommended HF treatments are not contraindicated in COPD and have favorable effects. Accurate diagnosis and therapy is crucial for effective treatment, reducing hospital readmissions and associated costs. The management considerations discussed in this study can potentially be extended to address other cardiopulmonary challenges frequently encountered by COPD patients.

Clinical Implication of N-Terminal Pro-Brain Natriuretic Peptide Burden in Heart Failure With Reduced Ejection Fraction: From the GUIDE-IT

This study aimed to explore the prognostic implication of N-terminal pro-brain natriuretic peptide (NT-proBNP) burden on heart failure (HF) with reduced ejection fraction (HFrEF). We performed a post hoc analysis of the GUIDing Evidence Based Therapy Using Biomarker Intensified Treatment in Heart Failure (GUIDE-IT) trial. NT-proBNP burden was defined as the proportion of days with increased NT-proBNP (≥1,800 pg/ml) to the whole observation time. A Cox proportional hazards regression model was used to evaluate the association with NT-proBNP burden and prognosis. A total of 815 patients with HFrEF were analyzed in our study. Patients were categorized into 4 groups according to the degree of NT-proBNP burden. In the multivariate Cox analysis, NT-proBNP burden was significantly associated with all-cause mortality, cardiovascular mortality, and HF hospitalization. Compared with patients without NT-proBNP burden, the risk for the composite outcome increased by 210% (hazard ratio [HR] 3.10, 95% confidence interval [CI] 1.72 to 5.58, p <0.001) in NT-proBNP burden 1 (mild) group, 432% (HR 5.32, 95% CI 2.93 to 9.67, p <0.001) in NT-proBNP burden 2 (moderate) group, and over 12 times (HR 13.15, 95% CI 7.42 to 23.33, p <0.001) in NT-proBNP burden 3 (severe) group. The sensitivity analyses stratified by age and renal function yielded similar results. A higher NT-proBNP burden was associated with a significant increase in risks of all-cause mortality, cardiovascular mortality, HF hospitalization, and composite outcome. The results suggested that NT-proBNP burden could be an important predictor of the prognosis of patients with HFrEF.

[Contribution of the 6-minutes walking test and the plasma NT-proBNP at admission and discharge to the prognostic evaluation of patients with NYHA class II-III Heart Failure.]

OBJECTIVE

To study the 6MWT and NT-proBNP contribution to the prognosis evaluation of patients with NYHA class II-III heart failure in the Yalgado Ouédraogo Teaching Hospital.

METHODS

We carried out a nine months prospective observational cohort from the 1st February to the 31st October 2020. Patients with NYHA class II-III HF who consented to participate were included in the study. We identified two variables of interest: death and readmission.

RESULTS

We included 50 patients with congestive heart failure representing 37.3% of heart failure. The average follow up time of patients was 154.58 ± 74.8 days. Twelve patients (24%) were readmited and 11 passed away with five during hospitalisation. On admission, The average distance on the 6MWT (194.6 ± 85.5 m) on admission and average NT-proBNP (5812.1±4729.4 ng/L) measured on admission and before discharge wasn't significantly correlated to the risk of death and re-hospitalisation. The average distance on the 6MWT before discharge (306.2±84.6) was significantly correlated to an increase risk of death and re-hospitalisation. Patients with an increase in NT-proBNP superior to 30% from measurement on admission to the one before discharge had a high risk of re-hospitalisation and death compare to those with a decrease of more than 30% with a moderate to good correlation coefficient of 0.6 between the two.

CONCLUSION

6MWT and NT-proBNP variations from admission to discharge have been necessary to evaluate the prognosis of patients with CHF.

Ceruloplasmin, NT-proBNP, and Clinical Data as Risk Factors of Death or Heart Transplantation in a 1-Year Follow-Up of Heart Failure Patients

We investigated whether the additional determination of ceruloplasmin (Cp) levels could improve the prognostic value of N-terminal pro-B-type natriuretic peptide (NT-proBNP) in heart failure (HF) patients in a 1-year follow-up. Cp and NT-proBNP levels and clinical and laboratory parameters were assessed simultaneously at baseline in 741 HF patients considered as possible heart transplant recipients. The primary endpoint (EP) was a composite of all-cause death (non-transplant patients) or heart transplantation during one year of follow-up. Using a cut-off value of 35.9 mg/dL for Cp and 3155 pg/mL for NT-proBNP (top interquartile range), a univariate Cox regression analysis showed that Cp (hazard ratio (HR) = 2.086; 95% confidence interval (95% CI, 1.462–2.975)), NT-proBNP (HR = 3.221; 95% CI (2.277–4.556)), and the top quartile of both Cp and NT-proBNP (HR = 4.253; 95% CI (2.795–6.471)) were all risk factors of the primary EP. The prognostic value of these biomarkers was demonstrated in a multivariate Cox regression model using the top Cp and NT-proBNP concentration quartiles combined (HR = 2.120; 95% CI (1.233–3.646)). Lower left ventricular ejection fraction, VO₂max, lack of angiotensin-converting enzyme inhibitor or angiotensin receptor blocker therapy, and nonimplantation of an implantable cardioverter-defibrillator were also independent risk factors of a poor outcome. The combined evaluation of Cp and NT-proBNP had advantages over separate NT-proBNP and Cp assessment in selecting a group with a high 1-year risk. Thus multi-biomarker assessment can improve risk stratification in HF patients.

The Role of Serial NT-ProBNP Level in Prognosis and Follow-Up Treatment of Acute Heart Failure after Coronary Artery Bypass Graft Surgery

BACKGROUND:

After coronary artery bypass graft (CABG) surgery, heart failure is still major problem. The valuable marker for it is needed.

AIM:

Evaluating the role of serial NT-proBNP level in prognosis and follow-up treatment of acute heart failure after CABG surgery.

METHODS:

The prospective, analytic study evaluated 107 patients undergoing CABG surgery at Ho Chi Minh Heart Institute from October 2012 to June 2014. Collecting data was done at pre- and post-operative days with measuring NT-proBNP levels on the day before operation, 2 hours after surgery, every next 24 h until the 5^th day, and in case of acute heart failure occurred after surgery.

RESULTS:

On the first postoperative day (POD1), the NT-proBNP level demonstrated significant value for AHF with the cut-off point = 817.8 pg/mL and AUC = 0.806. On the second and third postoperative day, the AUC value of NT- was 0.753 and 0.751. It was statistically significant in acute heart failure group almost at POD 1 and POD 2 when analyzed by the doses of dobutamine, noradrenaline, and adrenaline (both low doses and normal doses).

CONCLUSION:

Serial measurement of NT-proBNP level provides useful prognostic and follow-up treatment information in acute heart failure after CABG surgery.

The role of N-terminal pro-B-type natriuretic peptide in prognostic evaluation of heart failure

Heart failure (HF) is a growing challenge in the Asia Pacific region. N-terminal pro-B-type natriuretic peptide (NT-proBNP) is a well-established tool for diagnosis of HF; however, it is relatively underutilized in predicting adverse outcomes in HF. Multiple studies have demonstrated the prognostic role of NT-proBNP in HF. A single value of NT-proBNP >5000 pg/mL predicts a worse outcome in hospitalized patients with HF with reduced ejection fraction (HFrEF). In stable outpatients with HFrEF, NT-proBNP > 1000 pg/mL predicts a poorer prognosis. NT-proBNP provides the same prognostic information in patients with HF with preserved ejection fraction (HFpEF) as in those with HFrEF. An expert panel composed of cardiologists mainly from Asia Pacific region was convened to discuss the utility of NT-proBNP in HF prognostication. This article summarizes available scientific evidence and consensus recommendations from the meeting.

Rationale and design of MinerAlocorticoid Receptor antagonist Tolerability Study-Heart Failure (ARTS-HF): a randomized study of finerenone vs. eplerenone in patients who have worsening chronic heart failure with diabetes and/or chronic kidney disease

AIMS

To investigate the safety and potential efficacy of the novel non-steroidal mineralocorticoid receptor antagonist finerenone in patients with worsening chronic heart failure and reduced left ventricular ejection fraction (HFrEF) and at high risk of hyperkalaemia and worsening renal dysfunction.

METHODS AND RESULTS

The MinerAlocorticoid Receptor antagonist Tolerability Study-Heart Failure (ARTS-HF; NCT01807221) is a multicentre, randomized, double-blind, active-comparator-controlled, six-parallel-group, phase 2b dose-finding study. In total, 1060 patients with HFrEF and concomitant type 2 diabetes mellitus and/or chronic kidney disease (CKD) will be randomized within 7 days of emergency presentation to hospital for worsening chronic HF to receive finerenone (one of five doses in the range 2.5-20.0 mg once daily) or eplerenone (25 mg every second day to 50 mg once daily for 90 days). The primary objective is to investigate the safety and potential efficacy (measured as the percentage of individuals with a decrease in plasma N-terminal pro-B-type natriuretic peptide [NT-proBNP] of more than 30% relative to baseline at day 90 ± 2) of different oral doses of finerenone compared with eplerenone. Other objectives are to assess the effects of finerenone on a composite clinical endpoint (death from any cause, cardiovascular hospitalizations, or emergency presentations for worsening chronic HF), and on changes in health-related quality of life from baseline.

CONCLUSIONS

ARTS-HF is the first phase 2b clinical trial to investigate the effects of finerenone on plasma NT-proBNP in a high-risk population of patients who have worsening chronic HF with type 2 diabetes mellitus and/or CKD presenting at the emergency department.

N-terminal-pro-brain natriuretic peptide, a surrogate biomarker of combined clinical and hemodynamic outcomes following percutaneous transvenous mitral commissurotomy

Aim

To examine the relationship between plasma levels of N-terminal-proB type natriuretic peptide (NT-proBNP) and various echocardiographic and hemodynamic parameters in patients with mitral stenosis undergoing percutaneous transvenous mitral commissurotomy (PTMC).

Materials and methods

The study population consisted of 100 patients with rheumatic mitral stenosis who underwent PTMC. NT-proBNP levels in these patients were measured before PTMC and 48 hours after PTMC. These levels were then correlated with various echocardiographic and hemodynamic parameters measured before and after PTMC.

Results

Eighty-one percent of the study population were women, and the most common presenting symptom was dyspnea which was present in 94% of the patients. Dyspnea New York Heart Association class correlated significantly with baseline NT-proBNP levels (r = 0.63; p < 0.01). The plasma NT-proBNP levels in these patients increased as echocardiogram signs of left atrial enlargement and right ventricular hypertrophy developed (r = 0.59, p < 0.01). Patients in atrial fibrillation had significantly higher NT-proBNP levels than patients in sinus rhythm. Baseline NT-proBNP levels correlated significantly with left atrial volume (r = 0.38; p < 0.01), left atrial volume index (r = 0.45; p < 0.01), systolic pulmonary artery pressures (r = 0.42; p < 0.01), and mean pulmonary artery pressures (r = 0.41; p < 0.01). All patients who underwent successful PTMC showed a significant decrease in NT-proBNP (decreased from a mean 763.8 pg/mL to 348.6 pg/mL) along with a significant improvement in all echocardiographic and hemodynamic parameters (p < 0.01). The percent change in NT-proBNP correlated significantly with the percent improvement noted with left atrial volume (r = 0.39; p < 0.01), left atrial volume index (r = 0.41; p < 0.01), systolic (r = 0.32, p < 0.01), and mean pulmonary artery pressures (r = 0.31, p < 0.01).

Conclusions

The decrease in NT-proBNP levels following PTMC reflects an improvement in clinical and hemodynamic status; hence, it is reasonable to suggest that NT-proBNP is helpful in evaluating the response to PTMC.

Hemoconcentration-guided diuresis in heart failure

One quarter of patients hospitalized for heart failure are readmitted within 30 days, perhaps related to ineffective decongestion. Limited data exist guiding the extent and duration of diuresis in patients hospitalized for heart failure. The objective of this review was to determine the prognostic value of hemoconcentration, or the relative increase in the cellular elements in blood, in patients hospitalized for heart failure and to clarify its role in guiding inpatient diuretic practices. Six post hoc retrospective studies from 2010 to 2013 were available for review. Hemoconcentration was consistently associated with markers of aggressive fluid removal, including higher diuretic dosing and reduced body weight, but increased risk of in-hospital worsening renal function. Despite this, hemoconcentration was associated with improved short-term mortality and rehospitalization. Hemoconcentration is a practical, readily available, noninvasive, economically feasible strategy to help guide diuresis and monitor congestion relief in patients hospitalized for worsening heart failure. Clinicians should strongly consider using changes in hemoglobin and hematocrit as an adjunct to other available measures of decongestion and clinical acumen in inpatient heart failure care.

Efficacy and safety of the pulsed infusions of levosimendan in outpatients with advanced heart failure (LevoRep) study: a multicentre randomized trial

AIMS

The aim of this study was to determine whether intermittent ambulatory treatment with levosimendan would improve functional capacity, quality of life, and event-free survival in patients with advanced heart failure.

METHODS AND RESULTS

This was a prospective, randomized, double-blind, placebo-controlled, multicentre, parallel-group trial of pulsed infusions of levosimendan in 120 outpatients with advanced heart failure (EF ≤35%, NYHA class III or IV). The study was conducted at 11 centres in Austria, Greece, and Germany. Levosimendan (0.2 µg/kg/min) or placebo was administered for 6 h at 2-week intervals over 6 weeks, in addition to standard care therapy. The primary outcome was the proportion of patients with a ≥20% improvement in the 6 min walk test and a ≥15% score increase on the Kansas City Cardiomyopathy Questionnaire at the end of the 24-week study period. Secondary outcomes included event-free survival after 24 weeks. Analyses were performed on an intention-to-treat basis. The primary endpoint was reached in 19% of patients receiving levosimendan and 15.8% of patients receiving placebo (odds ratio 1.25; 95% confidence interval 0.44-3.59; P = 0.810). Cardiac death (four vs. one), heart transplants (two vs. one), and acute heart failure (14 vs. nine) were more frequent with placebo as compared with levosimendan. The incidence of side effects was comparable between groups.

CONCLUSION

Intermittent ambulatory treatment with levosimendan in patients with advanced heart failure did not improve significantly functional capacity or quality of life as compared with placebo. An adequately powered, event-driven trial is warranted to enlarge on our findings.

TRIAL REGISTRATION

NCT01065194.

Management of chronic heart failure guided by individual N-terminal pro-B-type natriuretic peptide targets: results of the PRIMA (Can PRo-brain-natriuretic peptide guided therapy of chronic heart failure IMprove heart fAilure morbidity and mortality?) study

OBJECTIVES

The purpose of this study was to assess whether management of heart failure (HF) guided by an individualized N-terminal pro-B-type natriuretic peptide (NT-proBNP) target would lead to improved outcome compared with HF management guided by clinical assessment alone.

BACKGROUND

Natriuretic peptides may be attractive biomarkers to guide management of heart failure (HF) and help select patients in need of more aggressive therapy. The PRIMA (Can PRo-brain-natriuretic peptide guided therapy of chronic heart failure IMprove heart fAilure morbidity and mortality?) study is, to our knowledge, the first large, prospective randomized study to address whether management of HF guided by an individualized target NT-proBNP level improves outcome.

METHODS

A total of 345 patients hospitalized for decompensated, symptomatic HF with elevated NT-proBNP levels at admission were included. After discharge, patients were randomized to either clinically-guided outpatient management (n = 171), or management guided by an individually set NT-proBNP (n = 174) defined by the lowest level at discharge or 2 weeks thereafter. The primary end point was defined as number of days alive outside the hospital after index admission.

RESULTS

HF management guided by this individualized NT-proBNP target increased the use of HF medication (p = 0.006), and 64% of HF-related events were preceded by an increase in NT-proBNP. Nevertheless, HF management guided by this individualized NT-proBNP target did not significantly improve the primary end point (685 vs. 664 days, p = 0.49), nor did it significantly improve any of the secondary end points. In the NT-proBNP-guided group mortality was lower, as 46 patients died (26.5%) versus 57 (33.3%) in the clinically-guided group, but this was not statistically significant (p = 0.206).

CONCLUSIONS

Serial NT-proBNP measurement and targeting to an individual NT-proBNP value did result in advanced detection of HF-related events and importantly influenced HF-therapy, but failed to provide significant clinical improvement in terms of mortality and morbidity. (Effect of NT-proBNP Guided Treatment of Chronic Heart Failure [PRIMA]; NCT00149422).

Log-transformation improves the prognostic value of serial NT-proBNP levels in apparently stable pulmonary arterial hypertension

N-terminal pro B-type natriuretic peptide (NT-proBNP) is a product of cleavage of the cardiac prohormone pro B-type natriuretic peptide into its active form. It has proven to be a useful biomarker in left heart failure. However, studies examining the utility of serial measurements of NT-proBNP in pulmonary arterial hypertension (PAH) patients have shown mixed results. We compared three methods of predicting adverse clinical outcomes in PAH patients: the change in 6 minute walk distance (6MWD), the change in absolute levels of NT-proBNP and the change in log-transformed levels of NT-proBNP. All PAH patients presenting from March-June 2007 were screened. Patients who were clinically unstable, had abnormal renal function or hemoglobin levels or lacked a prior NT-proBNP were excluded. 63 patients were followed up for adverse clinical outcomes (defined as death, transplantation, hospitalisation for right heart failure, or need for increased therapy). Three methods were used to predict adverse events, i.e.: (a) comparing a 6MWD performed in March-June 2007 and a previous 6MWD. A decrease in 6MWD of ≥30m was used to predict clinical deterioration; (b) comparing a NT-proBNP value measured in March-June 2007 and a previous NT-proBNP. An increase in NT-proBNP of ≥250pg/ml was used to predict clinical deterioration (250pg/ml represented approximately 30% change from the baseline median value of NT-proBNP for this cohort); and (c) comparing the loge equivalents of two consecutive NT-proBNP values. We used the formula: loge(current NT-proBNP) - loge(previous NT-proBNP)=x. A value of x≥+0.26 was used to predict adverse events. This is equivalent to a 30% change from baseline, and hence is comparable to the chosen cut-off for absolute levels of NT-proBNP. A loge difference of ≥+0.26 identifies patients at risk of adverse events with a specificity of 98%, a sensitivity of 60%, a positive predictive value of 89%, and a negative predictive value of 90%. A drop in 6MWD of ≥30m has a specificity of 29%, a sensitivity of 73%, a positive predictive value of 24% and a negative predictive value of 24%. It seems possible to risk-stratify apparently stable PAH patients by following the changes in their serial log-transformed NT-proBNP values. In this small pilot study, this method was better than relying on changes in the actual levels of NT-proBNP or changes in 6MWD. This needs to be validated prospectively in a larger cohort.

The use of the Internet to remotely monitor patients with heart failure

Heart failure (HF) results in high hospitalization rates and healthcare costs. Telemonitoring of HF has been shown to result in improved outcomes but usually involves the use of expensive equipment. A more feasible alternative may be the use of a Web site. The purpose of this study is to investigate the use of a Web site designed for HF telemonitoring. Patients newly referred to a heart function clinic were screened for eligibility. Twenty participants were recruited and entered their weight and symptoms onto the Web site for 6 months. A nurse monitored the Web site for changes in participant health status and telephoned the participants as necessary. Self-care, quality of life, 6-minute walk test, and N-terminal prohormone brain natriuretic peptide (NT-proBNP) were assessed. Interviews were conducted to assess intervention uptake. Seventeen participants completed the study. A significant change was observed on the maintenance subscale of the Self-Care of Heart Failure Index (p = 0.039). There was a trend toward improvement on the confidence subscale of the Self-Care of Heart Failure Index (p = 0.069), Minnesota Living With Heart Failure((R)) Questionnaire (p = 0.337), 6-minute walk test (p = 0.124), and NT-proBNP (p = 0.210). Participants and nurses demonstrated a favorable uptake of the Web site. A Web site that facilitates the telemonitoring of patients with HF was favorably accepted and its use in this pilot study was associated with improved self-care skills. However, further investigation is warranted in a larger study population.

Prognostic value of brain natriuretic peptide in acute heart failure: mortality and hospital readmission

The prognostic value of brain natriuretic peptide (BNP) measurement in patients with acute heart failure is not well understood. The aim of this study was to investigate the relationship between the BNP level and mortality and readmission for acute heart failure. We studied 569 consecutive patients who were admitted with a diagnosis of acute heart failure. The BNP level was measured after the patient became clinically stable. The relationship between the BNP level and mortality was assessed by Cox regression analysis, and the relationship with readmission, by competing risks regression analysis. During a median follow-up period of 9 (range, 3-18) months, 156 deaths (27.4%) and 140 readmissions (24.6%) occurred. Multivariate analysis demonstrated a positive linear association between the risk of death and the BNP quintile. In contrast, the BNP level did not predict readmission for acute heart failure, mainly because of the effect of death as a competing outcome.

[NT-proBNP in practice: from chemistry to medicine]

Since the introduction of routine assay for natriuretic peptides, there are a growing number of clinical applications for those new tests. Numerous studies have defined analytical characteristics and clinical interest of NT-proBNP assay. Originally limited to acute heart failure diagnosis in the emergency room, NT-proBNP assay has now a wide number of applications. This literature review presents the "state of art" of this marker, detailing NT-proBNP physiological recent knowledge and its recognized or investigated clinical applications.

N-terminal protype-B natriuretic peptide and Doppler diastolic variables are incremental for risk stratification of patients with NYHA class I-II systolic heart failure

BACKGROUND

In systolic heart failure (HF), preventing the development of severe symptoms, before patients are in advanced NYHA functional classes, is a worthwhile target of therapy. Early recognition of left ventricular (LV) diastolic dysfunction and neuroendocrine activation may have an important impact on patient's outcome.

AIM

To investigate whether N-terminal proBNP (NT-proBNP) and mitral flow and tissue Doppler (TD) diastolic parameters are incremental for risk stratification of systolic HF patients in NYHA class I and II.

METHODS

The study consisted of 232 consecutive outpatients with systolic HF (ejection fraction [EF] <or=45%) in NYHA class I to II. They had a full Doppler two-dimensional-echocardiographic study, including pulsed-Doppler mitral E wave deceleration time (EDT) and TD early septal annular velocity (E'). Plasma NT-proBNP was assessed at the time of the echocardiogram.

RESULTS

During a median follow-up of 31 months, there were 65 events (25 deaths and 40 HF-related hospitalizations). Multivariate analysis showed that N-terminal proBNP >544 pg/ml (hazards ratio [HR]: 2.66; p=0.012), EF <37% (HR: 2.45; p=0.006), E <or=8 cm/s (HR: 1.84; p=0.045) and EDT <150 ms (HR: 1.78; p=0.026) significantly correlated with events. On forward stepwise analysis, EDT (p<0.0001) and E' (p<0.0001) provided an incremental contribution to the outcome prediction above and beyond conventional risk markers, that was further increased by the addition of NT-proBNP (p<0.0001).

CONCLUSION

In patients with systolic HF in NYHA functional class I and II, N-terminal proBNP and LV mitral flow and TD variables of diastolic dysfunction had a strong predictive power for the combined end point of all-cause mortality and HF-related hospitalizations.

Usefulness of clinical and NT-proBNP monitoring for prognostic guidance in destabilized heart failure outpatients

AIMS

To study the relative prognostic value of N-terminal pro-B-type natriuretic peptide (NT-proBNP) monitoring in addition to clinical disease severity scores (CDSSs) in outpatients with destabilized heart failure (HF).

METHODS AND RESULTS

Seventy-one outpatients with recently destabilized HF were recruited. At baseline, and at all following visits, a CDSS based on Framingham criteria was obtained, and NT-proBNP levels were measured in a blind fashion. CDSS did not correlate with NT-proBNP levels at any time (P > 0.1), although their relative changes correlated during follow-up (P < 0.001). Forty patients (56%) had clinical events (cardiovascular death and/or HF hospitalization) within 1 year of follow-up. Changes in CDSS from baseline were not predictive of subsequent events (P > 0.1 for all visits), whereas changes in NT-proBNP levels were predictive at several time points: week 2 (P = 0.005), week 3 (P = 0.037), week 4 (P = 0.015), and 6 months (P = 0.026). A change in NT-proBNP levels at follow-up week 2 (%) added independent prognostic information (P < 0.001, HR 0.982, 95% CI 0.972-0.992) to baseline CDSS (P = 0.002, HR 2.05, 95% CI 1.290-3.266), age (P = 0.007, HR 1.034, 95% CI 1.009-1.059), and left ventricular ejection fraction (P = 0.013, HR 0.942, 95% CI 0.898-0.987).

CONCLUSION

Serial monitoring for per cent change in NT-proBNP concentrations offers superior prognostic information to clinical assessment among outpatients with recent destabilized HF.

Amino-terminal pro-B-type natriuretic peptide testing for inpatient monitoring and treatment guidance of acute destabilized heart failure

Although typically elevated at presentation in the context of destabilized heart failure (HF), amino-terminal pro-B-type natriuretic peptide (NT-proBNP) values typically decrease rapidly among patients who have a favorable response to therapy. Given this, it is natural to examine the relation between NT-proBNP and therapeutic interventions for acute HF. Both presentation and posttreatment NT-proBNP concentrations have some value for prognostication of recurrent HF hospitalization or death. However, the percent change in NT-proBNP after treatment for acute HF may be a more powerful method for risk stratification. Although prospective studies on the effect of NT-proBNP measurement in guiding therapy in acute destabilized HF are lacking, observational data suggest that a 30% decrease in NT-proBNP values during hospitalization is a reasonable goal. If a baseline measure of NT-proBNP is not available, an NT-proBNP level <4,000 ng/L after acute treatment is an alternative goal. Because the criteria for determining restabilization from destabilized HF prominently include clinical and routine laboratory testing rather than NP measures, the frequency of NT-proBNP measurement should not be excessive in patients with acute HF, with measures at baseline/presentation and after perceived recompensation to evaluate for the desired decrease in NT-proBNP concentrations. A remeasurement of NT-proBNP may also be useful for evaluation of new or worsened symptoms. In those patients without a decrease in NT-proBNP despite perceived recompensation from HF, a review of adequacy of treatment, goals of therapy, and consideration of prognosis is recommended.