Reduction in natriuretic peptide levels associated with improved outcome after ADHF
medwireNews: Achieving predischarge thresholds for reduction in natriuretic peptide (NP) levels is associated with reduced risks for mortality and hospital readmission in patients with acute decompensated heart failure (ADHF), the results of a systematic review suggest.
Craig Umscheid (University of Pennsylvania Health System, Philadelphia, USA) and colleagues found that achievement of threshold brain-type NP (BNP) or amino-terminal pro–brain-type NP (NT-proBNP) levels prior to hospital discharge was associated with a significant reduction in mortality risk in 14 of 16 studies, readmission risk in three of five studies, and a composite of mortality and readmission risk in 31 of 33 studies.
“[O]ur systematic review suggests a potential role for BNP and NT-proBNP levels beyond prognosis to help providers assess the quality of inpatient care for patients admitted for ADHF and to improve patient outcomes after discharge,” write the researchers in the Annals of Internal Medicine.
Umscheid and team analyzed the results of 44 studies investigating NP discharge thresholds, including one randomized controlled trial, three quasi-experimental studies, and 40 observational studies. The mean 6-month all-cause mortality and readmission rates were 15.3% and 30.3%, respectively.
In an accompanying commentary, G Michael Felker (Duke University Medical Center, Durham, North Carolina, USA) and David Whellan (Sidney Kimmel Medical College, Philadelphia, Pennsylvania, USA) note that “patients who achieve a substantial decrease in NP levels during in-hospital treatment tend to have better outcomes than those who do not.”
“This seems to be true regardless of the choice of biomarker (BNP or NT-proBNP) or whether the decrease is absolute (to a specific threshold value) or relative (a percentage decrease from an earlier value, typically at hospitalization),” they observe.
The researchers divided the studies included in their systematic review into those investigating reduction of NP to a target level (primarily a BNP level of 250 pg/mL or lower) and those focusing on a percentage reduction (primarily a decrease in NT-proBNP levels of 30% or more).
Achievement of an absolute target BNP level before discharge was associated with a significant reduction in mortality rates in seven of eight studies (hazard ratio [HR]=0.08–0.82), readmission in two of three studies (HR=0.07–0.97), and a composite of mortality and readmission in 11 of 13 studies (HR =0.07–0.78).
Similarly, achieving a percentage change BNP threshold before discharge was associated with reduced rates of mortality in three of four studies (HR=0.12–0.69) and a composite of mortality and readmission in four of five studies (HR=0.25–0.54). Reaching a percentage change NT-proBNP threshold was associated with reduced risk for mortality, readmission, and the composite measure in two of four studies (HR=0.13–0.58), one of two studies (HRs=0.38 and 0.70), and nine of nine studies (HR=0.26–0.64), respectively.
The study authors caution that the publications included in their study “consisted mostly of studies with high risk of bias,” and therefore “the evidence supporting an association between achievement of a predischarge NP threshold and decreased rates of mortality and readmission was rated as low-strength for all comparisons.”
They highlight the need for a “well-designed and well-executed randomized, controlled trial with a clear intervention algorithm” to establish the clinical benefits of targeting NP thresholds before discharge of patients with ADHF from hospital.
The commentators conclude that: “Even without a clinical trial, providers should consider incorporating NPs into their clinical practice as a means to risk-stratify patients; guide expectations; and inform treatment decisions, such as the need to consider palliative care or mechanical support.”
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