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BNP-Guided Heart Failure Therapy: Not for Everyone

In the TIME-CHF trial, some subgroups benefited from this strategy, but no overall reduction in patient-important outcomes was achieved.

Although B-type natriuretic peptide and N-terminal proBNP (NT-proBNP) are recognized prognostic markers in patients with heart failure, their utility in guiding pharmacotherapy for heart failure is not established. Supportive findings have emerged only from trials that were small, excluded older patients, or had design limitations (JW Cardiol Apr 25 2007). These investigators studied 499 symptomatic outpatients aged 60 with elevated NT-proBNP levels and histories of hospitalization for heart failure. Patients were randomized to receive medical therapy guided either by symptoms or by NT-proBNP levels (BNP-guided) and were stratified into two age groups (<75 and 75). The analysis excluded patients with preserved LV systolic function.

At baseline, most participants were receiving both ACE inhibitors or angiotensin-receptor blockers and beta-blockers. During follow-up, patients in the BNP-guided group had higher rates of protocol-recommended medication uptitration, received higher doses of both classes of medication, and were more likely to receive aldosterone antagonists than those in the symptom-guided group, regardless of age. At 18 months, no significant between-group difference was found in the primary endpoints of survival free of hospitalization for any cause and health-related quality of life. However, the rate of survival free of heart failure–related hospitalization (a secondary endpoint) was significantly higher in the BNP-guided group than in the symptom-guided group. In patients younger than 75, survival free of any hospitalization, overall survival, and survival free of heart failure–related hospitalization were all significantly higher in the BNP-guided group than in the symptom-guided group. Serious adverse-event rates were similar in the two groups. However, in the BNP-guided group, therapy-related adverse events occurred in more patients aged 75 than in younger patients (10.5% vs. 5.5%; P for age–intervention interaction=0.01).

Comment: These results indicate that using BNP levels to guide heart-failure pharmacotherapy increases doses of evidence-based medications but does not significantly improve overall patient outcomes. The subgroup analyses suggest that BNP-guided therapy is safe and perhaps even effective in younger patients, who have fewer coexisting illnesses than older patients and require less-complex treatment. However, further evidence is needed before this strategy can be recommended.

— Frederick A. Masoudi, MD, MSPH

Published in Journal Watch Cardiology January 27, 2009

Citation(s):

Pfisterer M et al. BNP-guided vs symptom-guided heart failure therapy: The Trial of Intensified vs Standard Medical Therapy in Elderly Patients with Congestive Heart Failure (TIME-CHF) randomized trial. JAMA 2009 Jan 28; 301:383.

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