Optimizing heart failure treatment using serial measurements of natriuretic peptides

Heart failure is when the heart does not pump blood sufficiently. Dominating symptoms are shortness of breath, fatigue and peripheral oedema. The disease is serious and may result in considerable impairment of quality of life and has a high mortality. The prognosis is often poor but may be improved if the disease is early diagnosed and the medical management and pharmacotherapy is optimized. Natriuretic peptides are used as biomarkers for diagnosis and prognosis for heart failure. The peptide levels also mirror changes in the level of heart failure. To optimize the clinical outcome serial measurements of natriuretic peptides has been used as a therapeutic tool.

Question

Is there evidence that adding serial measurements of natriuretic peptides in heart failure patients in primary care, improve outcomes like hospital readmissions and quality of life in these patients as compared with treatment according to guidelines?

Table with identified studies

Table 1. Systematic reviews with low/medium risk of bias
* = 12 RCT:s occurred in both of the systematic reviews

HF = Heart failure; LVEF = Left ventricular ejection fraction; NYHA = New York Heart Association; NP = Natriuretic peptide; BNP = B-type natriuretic peptide
Included studies Population/Intervention Outcome
Kahn et al 2018 [1]
18 RCT:s* (11 multi center and 7 single center studies, in total 5 116 patients)

One study was performed in primary care
Monitoring of natriuretic peptides in treatment of heart failure patients Total mortality, cardiovascular mortality, HF hospitalisations, all-cause hospitalisations, change in LVEF, change in NYHA class, symptomatic hypotension, and renal dysfunction
Authors' conclusion:
“This meta-analysis showed no significant reduction in mortality or HF-related hospitalizations with NP-guided therapy. The quality of evidence is affected by risk of bias in individual studies. NP-guided therapy should be further tested in a clinical trial which accounts for the current limitations.”
Pufulete et al 2018 [2]
14 RCT:s* (10 multicenter and 4 single center studies) in total 3 968 patients

One study was performed in primary care.
Monitoring of natriuretic peptides in treatment of heart failure patients Primary outcome: all cause mortality

Secondary outcomes: HF related death, cardiovascular death, all-cause hospitalisation, HF hospitalisation, adverse advents and quality of life
Authors' conclusion:
“BNP-guided therapy did not reduce mortality but reduced HF hospitalisation. The overall quality of the evidence varied from low to very low. The relevance of these findings to unselected patients, particularly those managed by community generalists, are unclear.”

References

  1. Khan MS, Siddiqi TJ, Usman MS, Sreenivasan J, Fugar S, Riaz H, et al. Does natriuretic peptide monitoring improve outcomes in heart failure patients? A systematic review and meta-analysis. Int J Cardiol 2018;263:80-87.
  2. Pufulete M, Maishman R, Dabner L, Higgins JPT, Rogers CA, Dayer M, et al. B-type natriuretic peptide-guided therapy for heart failure (HF): a systematic review and meta-analysis of individual participant data (IPD) and aggregate data. Syst Rev 2018;7:112.

SBU Enquiry Service consists of systematic literature searches to highlight studies that can address questions received by the SBU Enquiry Service from Swedish healthcare or social service providers. Relevant references are compiled by an SBU staff member, in consultation with an external expert when needed. The quality of the studies identified is not systematically reviewed.

Published: 7/1/2019
Contact SBU: registrator@sbu.se
Report no: ut201917
Registration no: 2017/1046

Literature search

Project group

Claes Lennmarken, Sally Saad, Sara Fundell and Miriam Entesarian Matsson at SBU.

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