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N-Terminal pro–B-type Natriuretic Peptide Is "Battle-Scarred" in Another Heart Failure Trial

Targeting care to achieve a specific NT-proBNP level added no value to intensive clinical management.

The most definitive studies about the value of using natriuretic peptide levels to guide management of heart failure have been largely disappointing. Indeed, current guidelines do not endorse the practice (JW Cardiol Aug 8 2007). In a new single-center trial, investigators in New Zealand randomized 364 patients with heart failure and an elevated baseline N-terminal pro–B-type natriuretic peptide (NT-proBNP) level to one of three strategies for 2 years: usual care, intensive clinical management guided by a clinical assessment score, or management guided by NT-proBNP level (target, <150 pmol/L) and by clinical score. The study population (mean age, 76) included patients with normal LV systolic function.

At 1 year, the biomarker-guided group and the group guided by clinical score alone had an identical all-cause mortality rate (9.1%) — significantly lower than that of the usual care group (18.9%). Among patients aged 75, mortality at 3 years was significantly lower in the biomarker-guided group (15.5%) than in the other two groups (about 31% in each), but that was a full year after the randomized interventions had stopped. Rates of readmission for heart failure did not differ significantly among the three groups.

Comment: Yet another trial has failed to show conclusive benefits from using natriuretic peptide levels to guide heart failure care, beyond the benefits of intensive clinical management. Although the 3-year mortality findings in the subgroup of patients aged 75 are consistent with data from the TIME-CHF trial (JW Cardiol Jan 27 2009), they are not adequate to support biomarker-guided treatment of heart failure in any population. Looking toward future trials, an editorialist provides numerous recommendations, including restricting enrollment to younger patients with systolic heart failure. Whether such studies will be conducted remains to be seen.

— Frederick A. Masoudi, MD, MSPH

Published in Journal Watch Cardiology February 10, 2010

Citation(s):

Lainchbury JG et al. N-terminal pro–B-type natriuretic peptide-guided treatment for chronic heart failure: Results from the BATTLESCARRED (NT-proBNP-Assisted Treatment to Lessen Serial Cardiac Readmissions and Death) trial. J Am Coll Cardiol 2010 Jan 5; 55:53.

• Original article (Subscription may be required)

Maisel A. Natriuretic peptide-guided therapy for heart failure: Ready for "battle" or too "scarred" by the challenges of trial design? J Am Coll Cardiol 2010 Jan 5; 55:61.

• Original article (Subscription may be required)