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BNP monitoring + protocol improves HF outcomes

Clinical Question:
In patients with heart failure, does regular monitoring of b-type natriuretic peptide, with subsequent intensification of drug therapy as appropriate, improve survival?

Bottom Line:
It seems that having a number to shoot for increases the use of mortality-reducing medications in the treatment of patients with heart failure. Routine monitoring of b-type natriuretic peptide (BNP) in patients with heart failure, with subsequent intensification of drug therapy for patients not at goal, results in improved survival in patients younger than 75 years. Simply aiming for target doses of beta-blockers and other survival-enhancing drugs may work as well, though perhaps it is the monitoring of this laboratory value that makes this appropriate dosing of drugs happen in clinical practice. (LOE = 1a)

Reference:
Porapakkham P, Porapakkham P, Zimmet H, Billah B, Krum H. B-type natriuretic peptide-guided heart failure therapy. A meta-analysis. Arch Intern Med 2010;170(6):507-514.  [PMID:20308637]

Study Design:
Meta-analysis (randomized controlled trials)

Funding:
Self-funded or unfunded

Setting:
Various (meta-analysis)

Synopsis:
The authors searched several databases, including the Cochrane controlled trials registry, and also searched for unpublished research presented at meetings to find all randomized controlled trials comparing BNP-guided treatment with usual care. Two authors independently selected studies for inclusion and abstracted the data. They identified 8 trials that enrolled a total of 1726 patients. The quality of the studies was not reported, but the authors excluded studies of fewer than 20 patients. There was no significant heterogeneity among the trials and little evidence of publication bias. The studies enrolled patients with heart failure and an ejection fraction of less than 50%, although the actual percentage was in the range of 30% for most of the patients. BNP-guided therapy, with associated guidelines for treatment escalation, increased the use of target doses of beta-blockers and angiotensin-converting enzyme inhibitors and decreased all-cause mortality (relative risk = 0.76; 95% CI, .63 - .91) over an average follow-up of 16 months. Analyzing by age group, all-cause mortality was significantly decreased in patients younger than 75 years but not for older patients. Hospitalizations were not decreased by guided therapy.

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