Accelerated up-titration of RAS antagonists and beta-blockers significantly reduced hospitalization or death due to cardiac disease in diabetic patients with elevated NT-proBNP (HR 0.351; 95% CI 0.127-0.975; p=0.044).
RCT (n=300)
Sí
Does intensified up-titration of RAS antagonists and beta-blockers reduce hospitalization or death due to cardiac disease in patients with type 2 diabetes, elevated NT-proBNP, and no history of cardiac disease?
NT-proBNP-guided up-titration of RAS antagonists and beta-blockers significantly reduced cardiac events in high-risk diabetic patients without prior cardiac disease.
Estimación del efecto: HR 0.351 (95% CI 0.127 to 0.975)
valor p: p=0.044
OBJECTIVES: The study sought to assess the primary preventive effect of neurohumoral therapy in high-risk diabetic patients selected by N-terminal pro-B-type natriuretic peptide (NT-proBNP). BACKGROUND: Few clinical trials have successfully demonstrated the prevention of cardiac events in patients with diabetes. One reason for this might be an inaccurate selection of patients. NT-proBNP has not been assessed in this context. METHODS: A total of 300 patients with type 2 diabetes, elevated NT-proBNP (>125 pg/ml) but free of cardiac disease were randomized. The "control" group was cared for at 4 diabetes care units; the "intensified" group was additionally treated at a cardiac outpatient clinic for the up-titration of renin-angiotensin system (RAS) antagonists and beta-blockers. The primary endpoint was hospitalization/death due to cardiac disease after 2 years. RESULTS: At baseline, the mean age of the patients was 67.5 ± 9 years, duration of diabetes was 15 ± 12 years, 37% were male, HbA1c was 7 ± 1.1%, blood pressure was 151 ± 22 mm Hg, heart rate was 72 ± 11 beats/min, median NT-proBNP was 265.5 pg/ml (interquartile range: 180.8 to 401.8 pg/ml). After 12 months there was a significant difference between the number of patients treated with a RAS antagonist/beta-blocker and the dosage reached between groups (p < 0.0001). Blood pressure was significantly reduced in both (p < 0.05); heart rate was only reduced in the intensified group (p = 0.004). A significant reduction of the primary endpoint (hazard ratio: 0.351; 95% confidence interval: 0.127 to 0.975, p = 0.044) was visible in the intensified group. The same was true for other endpoints: all-cause hospitalization, unplanned cardiovascular hospitalizations/death (p < 0.05 for all). CONCLUSIONS: Accelerated up-titration of RAS antagonists and beta-blockers to maximum tolerated dosages is an effective and safe intervention for the primary prevention of cardiac events for diabetic patients pre-selected using NT-proBNP. (Nt-proBNP Guided Primary Prevention of CV Events in Diabetic Patients PONTIAC; NCT00562952).
“Die Resultate sprechen bei gegebener Sicherheit klar für die hohe Effektivität einer Biomarker-gesteuerten, individualisierten Therapie”
Huelsmann et al. (Thu,) conducted a rct in Type 2 diabetes with elevated NT-proBNP but free of cardiac disease (n=300). Up-titration of renin-angiotensin system (RAS) antagonists and beta-blockers vs. Standard care at diabetes care units was evaluated on Hospitalization/death due to cardiac disease after 2 years (HR 0.351, 95% CI 0.127 to 0.975, p=0.044). Accelerated up-titration of RAS antagonists and beta-blockers significantly reduced hospitalization or death due to cardiac disease in diabetic patients with elevated NT-proBNP (HR 0.351; 95% CI 0.127-0.975; p=0.044).