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January 27, 2009JAMA

BNP-Guided vs Symptom-Guided Heart Failure Therapy

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Why the study?

Does BNP-guided therapy improve survival free of all-cause hospitalizations and quality of life in elderly patients with systolic heart failure compared to symptom-guided therapy?

Population

499 patients aged 60 years or older with systolic heart failure, prior hospitalization for heart failure…

Comparison

BNP-guided therapy: Uptitration of… vs Symptom-guided therapy: Uptitration of…

Design

RCT, Randomized

Follow-up

18 months

Authors

MPMatthias PfistererPBPeter BuserHRHans Rickli

Discussion

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Overview

BNP-guided therapy offers no all-cause benefit over symptom guidance in elderly systolic HF; challenges routine biomarker-directed intensification in this population.

Key Points

  • To evaluate whether intensifying medical therapy guided by N-terminal brain natriuretic peptide (BNP) improves 18-month survival free of all-cause hospitalizations and quality of life compared with symptom-guided therapy in elderly patients with systolic heart failure.
  • Multicenter randomized controlled trial (TIME-CHF, ISRCTN43596477) conducted across 15 outpatient centers in Switzerland and Germany with 18 months of follow-up.
  • Enrolled 499 patients aged 60 years or older with systolic heart failure (ejection fraction ≤ 45%, NYHA class ≥ II, prior heart failure hospitalization within 1 year, and N-terminal BNP ≥ 2 times the upper limit of normal).
  • Patients were randomized to uptitration of guideline-directed therapy targeting symptom relief alone (NYHA class ≤ II) or targeting both symptom relief and N-terminal BNP reduction (≤ 2 times the upper limit of normal).
  • Survival free of all-cause hospitalization at 18 months was similar between BNP-guided and symptom-guided groups (41% vs 40%; HR 0.91, 95% CI 0.72–1.14; P = .39), with comparable improvements in quality-of-life scores across both arms.
  • BNP-guided therapy significantly improved 18-month survival free of heart failure hospitalization compared with symptom-guided therapy (72% vs 62%; HR 0.68, 95% CI 0.50–0.92; P = .01).
  • BNP-guided therapy improved outcomes in patients aged 60 to 75 years but not in those aged 75 years or older (P < .02 for interaction).

Structured PICO

Does BNP-guided therapy improve survival free of all-cause hospitalizations and quality of life in elderly patients with systolic heart failure compared to symptom-guided therapy?

P
Population
499 patients aged 60 years or older with systolic heart failure (LVEF ≤45%, NYHA class ≥II), prior hospitalization for heart failure within 1 year, and N-terminal BNP level ≥2 times the upper limit of normal.
I
Intervention
BNP-guided therapy: Uptitration of guideline-based treatments to reduce symptoms to NYHA class ≤II and BNP level ≤2 times the upper limit of normal.
C
Comparator
Symptom-guided therapy: Uptitration of guideline-based treatments to reduce symptoms to NYHA class ≤II.
O
Outcome
18-month survival free of all-cause hospitalizations and quality of life as assessed by structured validated questionnaires.composite

In elderly patients with systolic heart failure, NT-proBNP-guided therapy did not improve survival free of all-cause hospitalizations or quality of life compared with symptom-guided therapy.

Cite This Study

Pfisterer et al. (2009) studied this question.

synapsesocial.com/papers/6a7d74f0e9ddcd9870aa218dhttps://doi.org/10.1001/jama.2009.2
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