NT-ProBNP reduction percentage during admission for acutely decompensated heart failure predicts long-term cardiovascular mortality

Clinical Implication of N-Terminal Pro-Brain Natriuretic Peptide Burden in Heart Failure With Reduced Ejection Fraction: From the GUIDE-IT

This study aimed to explore the prognostic implication of N-terminal pro-brain natriuretic peptide (NT-proBNP) burden on heart failure (HF) with reduced ejection fraction (HFrEF). We performed a post hoc analysis of the GUIDing Evidence Based Therapy Using Biomarker Intensified Treatment in Heart Failure (GUIDE-IT) trial. NT-proBNP burden was defined as the proportion of days with increased NT-proBNP (≥1,800 pg/ml) to the whole observation time. A Cox proportional hazards regression model was used to evaluate the association with NT-proBNP burden and prognosis. A total of 815 patients with HFrEF were analyzed in our study. Patients were categorized into 4 groups according to the degree of NT-proBNP burden. In the multivariate Cox analysis, NT-proBNP burden was significantly associated with all-cause mortality, cardiovascular mortality, and HF hospitalization. Compared with patients without NT-proBNP burden, the risk for the composite outcome increased by 210% (hazard ratio [HR] 3.10, 95% confidence interval [CI] 1.72 to 5.58, p <0.001) in NT-proBNP burden 1 (mild) group, 432% (HR 5.32, 95% CI 2.93 to 9.67, p <0.001) in NT-proBNP burden 2 (moderate) group, and over 12 times (HR 13.15, 95% CI 7.42 to 23.33, p <0.001) in NT-proBNP burden 3 (severe) group. The sensitivity analyses stratified by age and renal function yielded similar results. A higher NT-proBNP burden was associated with a significant increase in risks of all-cause mortality, cardiovascular mortality, HF hospitalization, and composite outcome. The results suggested that NT-proBNP burden could be an important predictor of the prognosis of patients with HFrEF.

Pre-discharge and early post-discharge management of patients hospitalized for acute heart failure: A scientific statement by the Heart Failure Association of the ESC

Acute heart failure is a major cause of urgent hospitalizations. These are followed by marked increases in death and rehospitalization rates, which then decline exponentially though they remain higher than in patients without a recent hospitalization. Therefore, optimal management of patients with acute heart failure before discharge and in the early post-discharge phase is critical. First, it may prevent rehospitalizations through the early detection and effective treatment of residual or recurrent congestion, the main manifestation of decompensation. Second, initiation at pre-discharge and titration to target doses in the early post-discharge period, of guideline-directed medical therapy may improve both short- and long-term outcomes. Third, in chronic heart failure, medical treatment is often left unchanged, so the acute heart failure hospitalization presents an opportunity for implementation of therapy. The aim of this scientific statement by the Heart Failure Association of the European Society of Cardiology is to summarize recent findings that have implications for clinical management both in the pre-discharge and the early post-discharge phase after a hospitalization for acute heart failure.

2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure.

METHODS

A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. Structure: Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.

2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure

AIM

The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure.

METHODS

A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021.

STRUCTURE

Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.

Effect of vitamin supplementation in patients of congestive heart failure deficient in vitamin D: A study at a tertiary care center of North India

Introduction

Heart Failure is a leading cause of mortality worldwide including India. Most cross sectional studies have demonstrated heart failure is associated with deficiency of essential micronutrients including Vitamin D which may play a important role in pathogenesis of ventricular remodelling in heart failure.

Aim

Our study performed aimed to determine the effect of supplementation in patients of Heart Failure presenting with Vitamin D deficiency to our institute on severity of Heart Failure.

Design and Method

97 patients of Heart failure coming to our institute were given conventional therapies for Heart Failure along with Vitamin supplementation based on serum Vitamin D levels and followed up for 3 months.

Results

Patient of Heart failure having Vitamin D deficiency had significant reduction in cardiac biomarkers (NT-pro BNP levels), improvement in Left ventricular ejection fraction (LVEF) and more favourable reverse remodelling determined by Left ventricular end diastolic and systolic diameter (LVEDD & LVESD) though quality of life determined by WHODAS 2.0 score did not changed following 12 weeks supplementation of High Dose Vitamin D.

Conclusion

Recognising and treatment of Vitamin D deficiency may determine long term prognosis in patients of Heart Failure.

Clinical Characteristics and Outcome of Immediate-Release Versus SLOW-Release Carvedilol in Heart Failure Patient (SLOW-HF): a Prospective Randomized, Open-Label, Multicenter Study

PURPOSE

Carvedilol demonstrated therapeutic benefits in patients with heart failure and reduced ejection fraction (HFrEF). However, it had a short half-life time mandating twice a day administration. We investigated whether slow-release carvedilol (carvedilol-SR) is non-inferior to standard immediate-release carvedilol (carvedilol-IR) in terms of clinical efficacy in patients with HFrEF.

METHODS

We randomly assigned patients with HFrEF to receive carvedilol-SR once a day or carvedilol-IR twice a day. The primary endpoint was the change in N-terminal pro B-natriuretic peptide (NT-proBNP) level from baseline to 6 months after randomization. The secondary outcomes were proportion of patients with NT-proBNP increment > 10% from baseline, mortality rate, readmission rate, changes in blood pressure, quality of life, and drug compliance.

RESULTS

A total of 272 patients were randomized and treated (median follow-up time, 173 days). In each group of patients taking carvedilol-SR and those taking carvedilol-IR, clinical characteristics were well balanced. No patient died during follow-up, and there was no significant difference in the change of NT-proBNP level between two groups (-107.4 [-440.2-70.3] pg/mL vs. -91.2 [-504.1-37.4] pg/mL, p = 0.101). Change of systolic and diastolic blood pressure, control rate and response rate of blood pressure, readmission rate, and drug compliance rate were also similar. For safety outcomes, the occurrence of adverse reactions did not differ between carvedilol-SR group and carvedilol-IR group.

CONCLUSION

Carvedilol-SR once a day was non-inferior to carvedilol-IR twice a day in patients with HFrEF.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03209180 (registration date: July 6, 2017).

Relation of Decongestion and Time to Diuretics to Biomarker Changes and Outcomes in Acute Heart Failure

Prompt treatment may mitigate the adverse effects of congestion in the early phase of heart failure (HF) hospitalization, which may lead to improved outcomes. We analyzed 814 acute HF patients for the relationships between time to first intravenous loop diuretics, changes in biomarkers of congestion and multiorgan dysfunction, and 1-year composite end point of death or HF hospitalization. B-type natriuretic peptide (BNP), high sensitivity cardiac troponin I (hscTnI), urine and serum neutrophil gelatinase-associated lipocalin, and galectin 3 were measured at hospital admission, hospital day 1, 2, 3 and discharge. Time to diuretics was not correlated with the timing of decongestion defined as BNP decrease ≥ 30% compared with admission. Earlier BNP decreases but not time to diuretics were associated with earlier and greater decreases in hscTnI and urine neutrophil gelatinase-associated lipocalin, and lower incidence of the composite end point. After adjustment for confounders, only no BNP decrease at discharge was significantly associated with mortality but not the composite end point (p = 0.006 and p = 0.062, respectively). In conclusion, earlier time to decongestion but not the time to diuretics was associated with better biomarker trajectories. Residual congestion at discharge rather than the timing of decongestion predicted a worse prognosis.

Biomarkers in Acute Heart Failure: Diagnosis, Prognosis, and Treatment

Heart failure is a global health problem. An episode of acute heart failure (AHF) is a period of substantial morbidity and mortality with few advances in the management of an episode that have improved outcomes. The measurement of multiple biomarkers has become an integral adjunctive tool for the management of AHF. Many biomarkers are now well established in their ability to assist with diagnosis and prognostication of an AHF patient. There are also emerging biomarkers that are showing significant promise in the areas of diagnosis and prognosis. For improving the management of AHF, both established and novel biomarkers may assist in guiding medical therapy and subsequently improving outcomes. Thus, it is important to understand the different abilities and limitations of established and emerging biomarkers in AHF so that they may be correctly interpreted and integrated into clinical practice for AHF. This knowledge may improve the care of AHF patients. This review will summarize the evidence of both established and novel biomarkers for diagnosis, prognosis and management in AHF so that the treating clinician may become more comfortable incorporating these biomarkers into clinical practice in an evidence-based manner.

NT-proBNP Response to Sacubitril/Valsartan in Hospitalized Heart Failure Patients With Reduced Ejection Fraction: TRANSITION Study

OBJECTIVES

This study examined the effects of sacubitril/valsartan on N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels and determined patient characteristics associated with favorable NT-proBNP reduction response.

BACKGROUND

NT-proBNP levels reflect cardiac wall stress and predict event risk in patients with acute decompensated heart failure (ADHF).

METHODS

Post-hoc analysis of the TRANSITION (Comparison of Pre- and Post-discharge Initiation of Sacubitril/Valsartan Therapy in HFrEF Patients After an Acute Decompensation Event) study, including stabilized ADHF patients with reduced ejection fraction, randomized to open-label sacubitril/valsartan initiation in-hospital (pre-discharge) versus post-discharge. NT-proBNP was measured at randomization (baseline), discharge, and 4 and 10 weeks post-randomization. A favorable NT-proBNP response was defined as reduction to ≤1,000 pg/ml or >30% from baseline.

RESULTS

In patients receiving sacubitril/valsartan in-hospital, NT-proBNP was reduced by 28% at discharge, with 46% of patients obtaining favorable NT-proBNP reduction response compared with a 4% reduction and 18% favorable response rate in patients initiated post-discharge (p < 0.001). NT-proBNP was reduced similarly in patients initiating sacubitril/valsartan pre- and post-discharge (reduction at 4 weeks: 25%/22%; 10 weeks: 38%/34%) with comparable favorable response rates (46%/42% and 51%/48% at 4 and 10 weeks, respectively). NT-proBNP favorable response at 4 weeks was associated with lower risk of first heart failure (HF) rehospitalization or cardiovascular death through 26 weeks (hazard ratio: 0.57; 95% confidence interval [CI]: 0.38 to 0.86; p = 0.007). Predictors of a favorable response at 4 weeks were starting dose ≥49/51 mg twice daily, higher baseline NT-proBNP, lower baseline serum creatinine, de novo HF, no atrial fibrillation, angiotensin-converting enzyme inhibitor-naive or angiotensin receptor blocker-naive, and no prior myocardial infarction.

CONCLUSIONS

In-hospital initiation of sacubitril/valsartan produced rapid reductions in NT-proBNP, statistically significant at discharge. A favorable NT-proBNP response over time was associated with a better prognosis and predicted by higher starting dose and predisposing clinical profile. (Comparison of Pre- and Post-discharge Initiation of LCZ696 Therapy in HFrEF Patients After an Acute Decompensation Event [TRANSITION]; NCT02661217).

Heart Failure With Reduced Ejection Fraction: A Review

IMPORTANCE

Worldwide, the burden of heart failure has increased to an estimated 23 million people, and approximately 50% of cases are HF with reduced ejection fraction (HFrEF).

OBSERVATIONS

Heart failure is a clinical syndrome characterized by dyspnea or exertional limitation due to impairment of ventricular filling or ejection of blood or both. HFrEF occurs when the left ventricular ejection fraction (LVEF) is 40% or less and is accompanied by progressive left ventricular dilatation and adverse cardiac remodeling. Assessment for heart failure begins with obtaining a medical history and physical examination. Also central to diagnosis are elevated natriuretic peptides above age- and context-specific thresholds and identification of left ventricular systolic dysfunction with LVEF of 40% or less as measured by echocardiography. Treatment strategies include the use of diuretics to relieve symptoms and application of an expanding armamentarium of disease-modifying drug and device therapies. Unless there are specific contraindications, patients with HFrEF should be treated with a β-blocker and one of an angiotensin receptor-neprilysin inhibitor, angiotensin-converting enzyme inhibitor, or angiotensin receptor blocker as foundational therapy, with addition of a mineralocorticoid receptor antagonist in patients with persistent symptoms. Ivabradine and hydralazine/isosorbide dinitrate also have a role in the care of certain patients with HFrEF. More recently, sodium-glucose cotransporter 2 (SGLT2) inhibitors have further improved disease outcomes, significantly reducing cardiovascular and all-cause mortality irrespective of diabetes status, and vericiguat, a soluble guanylate cyclase stimulator, reduces heart failure hospitalization in high-risk patients with HFrEF. Device therapies may be beneficial in specific subpopulations, such as cardiac resynchronization therapy in patients with interventricular dyssynchrony, transcatheter mitral valve repair in patients with severe secondary mitral regurgitation, and implantable cardiac defibrillators in patients with more severe left ventricular dysfunction particularly of ischemic etiology.

CONCLUSIONS AND RELEVANCE

HFrEF is a major public health concern with substantial morbidity and mortality. The management of HFrEF has seen significant scientific breakthrough in recent decades, and the ability to alter the natural history of the disease has never been better. Recent developments include SGLT2 inhibitors, vericiguat, and transcatheter mitral valve repair, all of which incrementally improve prognosis beyond foundational neurohormonal therapies. Disease morbidity and mortality remain high, with a 5-year survival rate of 25% after hospitalization for HFrEF.

An update on the use and discovery of prognostic biomarkers in acute decompensated heart failure

Introduction: Acute decompensated heart failure (ADHF) remains a significant health care burden as evidenced by high readmission rates and mortality. Over the years, the care of patients with ADHF has been transformed by the use of biomarkers, specifically to aid in the diagnosis and prognosis. Patients with HF follow a variable course given the complex and heterogenous pathophysiological processes, thus it is imperative for clinicians to have tools to predict short and long-term outcomes in order to educate patients and optimize management. Areas Covered: The natriuretic peptides, including B-type natriuretic peptide and N-terminal pro-B-type natriuretic peptide, are considered the gold standard biomarkers. Yet, other emerging biomarkers such as suppression of tumerogenicity-2, cardiac troponin, galectin-2, mid-regional pro-adrenomedullin, copeptin, cystatin, and neutrophil gelatinase-associated lipocalin have increasingly shown promise in evaluating prognosis in patients with ADHF. This article reviews the pathophysiology and utility of both established and emerging biomarkers for the prognostication of patients with ADHF. Expert Opinion: As of 2019, the most validated biomarkers for use in decompensated heart failure include natriuretic peptides, high sensitivity troponin, and sST2. These biomarkers are involved in the underlying pathophysiology of disease and as such provide added information to that of exam, x-ray, and echocardiography.

Prognostic Implications of Changes in Amino-Terminal Pro-B-Type Natriuretic Peptide in Acute Decompensated Heart Failure: Insights From ASCEND-HF

BACKGROUND

Amino-terminal pro-B-type natriuretic peptide (NTproBNP) is closely associated with prognosis in acute decompensated heart failure (ADHF). As a result, there has been great interest measuring it during the course of treatment. The prognostic implications in both short-term and follow-up changes in NTproBNP need further clarification.

METHODS

Baseline, 48-72 hour, and 30-day NTproBNP levels were measured in 795 subjects in the ASCEND-HF trial. Multivariable logistic and Cox-proportional hazards models were used to test the association between static, relative, and absolute changes in NTproBNP with outcomes during and after ADHF.

RESULTS

The median NTproBNP at baseline was 5773 (2981-11,579) pg/mL; at 48-72 hours was 3036 (1191-6479) pg/mL; and at 30 days was 2914 (1364-6667) pg/mL. Absolute changes in NTproBNP by 48-72 hours were not associated with 30-day heart failure rehospitalization or mortality (P = .065), relative changes in NTproBNP were nominally associated (P = .046). In contrast, both absolute and relative changes in NTproBNP from baseline to 48-72 hours and to 30 days were closely associated with 180-day mortality (P < .02 for all) with increased discrimination compared to the multivariable models with baseline NTproBNP (P <.05 for models with relative and absolute change at both time points).

CONCLUSIONS

Although the degree of absolute change in NTproBNP was dependent on baseline levels, both short-term absolute and relative changes in NTproBNP were independently and incrementally associated with long-term clinical outcomes. Changes in NTproBNP levels at 30-days were particularly well associated with long-term clinical outcomes.

NT-ProBNP Predicts Total Mortality, Emergency Department Visits, Hospitalization, Intensive-Care Unit Admission, and Cardiovascular Events in Hemodialysis Patients

N-terminal pro b-type natriuretic peptide (NT-proBNP) was considered a prognostic factor for mortality in hemodialysis patients in previous studies. However, NT-proBNP has not been fully explored in terms of predicting other clinical outcomes in hemodialysis patients. This study aimed to investigate if NT-proBNP could predict emergency department (ED) visits, hospitalization, admission to intensive-care unit (ICU), and cardiovascular incidents in hemodialysis patients. Serum NT-proBNP and other indicators were collected in 232 hemodialysis patients. Patients were followed up for three years or until mortality. Outcomes included mortality, number of ED visits, hospitalizations, admissions to ICU, and cardiovascular events. NT-proBNP was found to predict recurrent ER visits, hospitalization, admission to ICU, cardiovascular events, and mortality, after adjusting for covariates. Time-dependent area under the curve (AUC) was used to evaluate the NT-proBNP predicting ability. Using time-dependent AUC, NT-proBNP has good predictive ability for mortality, ED visit, hospitalization, ICU admission, and cardiovascular events with the best predictive ability occurring at approximately 1 year, and 5th, 62nd, 63rd, and 63rd days respectively. AUC values for predicting mortality, hospitalization, and ICU admission decreased significantly after one year. NT-proBNP can be applied in predicting ED visits but is only suitable for the short-term. NT-proBNP may be used for predicting mortality in the long term.

Complex assessment of patients with decompensated heart failure: The clinical value of impedance cardiography and N-terminal pro-brain natriuretic peptide

BACKGROUND

Acute decompensated heart failure (ADHF) is a serious clinical problem and a condition requiring immediate diagnostics, supporting the therapeutic decision adequate to the specific ADHF mechanism. N-terminal pro-brain natriuretic peptide (NT-proBNP) is an established biochemical marker of heart failure, strongly related to hemodynamic status. Impedance cardiography (ICG) provides non-invasive hemodynamic assessment that can be performed immediately at the bedside and revealed to be useful diagnostic tool in some clinical settings in cardiology.

OBJECTIVES

The aim of this study was to evaluate the usefulness of ICG in the admission diagnostics and monitoring the effects of treatment in patients hospitalized due to ADHF, with special emphasis on its relation to NT-proBNP.

METHODS

This study enrolled 102 patients, aged over 18 years, hospitalized due to ADHF. The subjects underwent detailed clinical assessment, including ICG and NT-proBNP at admission and at discharge day.

RESULTS

Among all analyzed ICG parameters thoracic fluid content (TFC), a marker of chest overload, was the most significantly correlated with NT-proBNP level (R = 0.46; p = 0.000001). In comparison with patients with low thoracic fluid content (TFC ≤ 35/kΩ), those with higher TFC values (>35/kΩ) exhibited a greater severity of symptoms (NYHA functional class); higher NT-proBNP levels; lower left ventricular ejection fraction (LVEF), stroke index (SI), and cardiac index (CI); as well as significantly higher systemic vascular resistance index (SVRI). These TFC-based subgroups showed no significant differences in terms of heart rate (HR), systolic blood pressure (SBP), or diastolic blood pressure (DBP).

CONCLUSIONS

The evaluation of hemodynamic parameters, especially TFC, seems to be a worthwhile addition to standard diagnostics, both at the stage of hospital admission and while monitoring the effects of treatment. Impedance cardiography is a useful method in evaluating individual hemodynamic profiles in patients with ADHF.

What Is New in Heart Failure Management in 2017? Update on ACC/AHA Heart Failure Guidelines

PURPOSE OF REVIEW

The goal of this paper is to provide a summary of the new recommendations in the most recent 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. The intent is to provide the background and the supporting evidence for the recommendations and to provide practical guidance for management strategies in treatment of heart failure patients.

RECENT FINDINGS

In the 2017 ACC/AHA/HFSA Focused Update of HF guidelines, important additions include new information on biomarkers, specifically on the topics of the diagnostic, prognostic role of natriuretic peptides in heart failure, and the role of natriuretic peptides in screening in patients high risk for HF and prevention of HF. There are important recommendations for treatment of patients with HF with reduced EF (HFrEF), including the beneficial role of angiotensin receptor blocker and neprilysin inhibition (ARNI) treatment in reducing outcomes including mortality, ivabradine in reducing heart failure hospitalizations in stable HFrEF patients with sinus rhythm and heart rate ≥ 70 bpm despite β-blockers. In patients with HF with preserved EF (HFpEF), though there are no studies demonstrating survival benefit, potential benefit with aldosterone antagonism in reducing HF hospitalizations is noted. In treatment of comorbidities, optimization of blood pressure control to less than 130 mmHg is recommended in hypertensive patients to prevent HF or in patients with hypertension and HFrEF or HFpEF. In addition to recognition on the potential role of treatment of iron deficiency anemia to improve symptoms and functional capacity, caution against use of adaptive servo-ventilation in patients with HFrEF and central sleep apnea and against use of erythropoietin stimulating agents in patients with HFrEF is provided. There are new treatment strategies that are associated with significant improvements in mortality and other outcomes in patients with HF. Successful management of HF requires recognition of indications, contraindications, benefits, safety, and risk of these new therapies. In addition to incorporation of these new treatment strategies, it is critical to focus also on patient education, care coordination, identification of goals of care, monitoring, management of comorbidities, and individualization of therapies. New treatment modalities increase the choices for treatment and provide the opportunity to implement individualized treatment strategies for our patients.

Prognostic performance of serial in-hospital measurements of copeptin and multiple novel biomarkers among patients with worsening heart failure: results from the MOLITOR study

Aims

In heart failure, various biomarkers are established for diagnosis and risk stratification; however, little is known about the relevance of serial measurements during an episode worsening heart failure (WHF). This study sought to investigate the trajectory of natriuretic peptides and multiple novel biomarkers during hospitalization for WHF and to determine the best time point to predict outcome.

Methods and results

MOLITOR (Impact of Therapy Optimisation on the Level of Biomarkers in Patients with Acute and Decompensated Chronic Heart Failure) was an eight‐centre prospective study of 164 patients hospitalized with a primary diagnosis of WHF. C‐terminal fragment of pre‐pro‐vasopressin (copeptin), N‐terminal pro‐B‐type natriuretic peptide (NT‐proBNP), mid‐regional pro‐atrial natriuretic peptide (MR‐proANP), mid‐regional pro‐adrenomedullin (MR‐proADM), and C‐terminal pro‐endothelin‐1 (CT‐proET1) were measured on admission, after 24, 48, and 72 h, and every 72 h thereafter, at discharge and follow‐up visits. Their performance to predict all‐cause mortality and rehospitalization at 90 days was compared. All biomarkers decreased during recompensation (P < 0.05) except MR‐proADM. Copeptin at admission was the best predictor of 90 day mortality or rehospitalization (χ² = 16.63, C‐index = 0.724, P < 0.001), followed by NT‐proBNP (χ² = 10.53, C‐index = 0.646, P = 0.001), MR‐proADM (χ² = 9.29, C‐index = 0.686, P = 0.002), MR‐proANP (χ² = 8.75, C‐index = 0.631, P = 0.003), and CT‐proET1 (χ² = 6.60, C‐index = 0.64, P = 0.010). Re‐measurement of copeptin at 72 h and of NT‐proBNP at 48 h increased prognostic value (χ² = 23.48, C‐index = 0.718, P = 0.00001; χ² = 14.23, C‐index = 0.650, P = 0.00081, respectively).

Conclusions

This largest sample of serial measurements of multiple biomarkers in WHF found copeptin at admission with re‐measurement at 72 h to be the best predictor of 90 day mortality and rehospitalization.

Prognostic value of short-term follow-up BNP in hospitalized patients with heart failure

Background

B-type natriuretic peptide (BNP) has prognostic significance in heart failure (HF), and reductions in BNP may predict clinical improvement. However, there are limited data regarding the prognostic value of BNP during short-term follow-up. The aim of this study was to evaluate the relationship between short-term follow-up BNP and mortality after discharge in patients with HF.

Methods

We analyzed 427 patients hospitalized with HF from the Wonju Severance Christian Hospital Heart Failure Registry from April 2011 to December 2013, with a planned follow-up period through February 2016. Of the 427 patients, 240 (mean age, 75 years; 102 males, 42.5%) had BNP measured on admission and within the short-term follow-up period (3 months). We compared all-cause mortality during the clinical follow-up period (median length of follow-up, 709.5 days) according to the median value of BNP on admission (as a baseline value) and over a short-term follow-up period after discharge.

Results

Median BNP at admission was 816.5 pg/ml, and median follow-up BNP was 369.7 pg/ml. Multivariate analysis revealed a positive association between risk of death and high BNP. High BNP during follow-up was significantly associated with a greater risk of all-cause mortality compared to low BNP (P < 0.001). Initial BNP was not significantly associated with all-cause mortality. A multivariate model showed that follow-up BNP and percent change in BNP were independently associated with all-cause mortality after adjustment for covariates. Of the 3 BNP measurement strategies, BNP after discharge (IDI of 0.072, P < .0001 and NRI of 0.707, P < .0001) and percent change in BNP (IDI of 0.113, P < .0001 and NRI of 0.782, P < .0001) demonstrated the greatest increase in discrimination and net reclassification for mortality. Unfortunately, we did not find any significant value with initial BNP. Kaplan-Meier survival analysis was performed to assess mortality stratified by BNP according to the median value, high median of follow-up BNP and percent change in BNP were associated with significantly higher mortality compared to the below median (log-rank, p < 0.001).

Conclusions

Short-term follow-up BNP and percent change in BNP level are significant prognostic factors of all-cause mortality. These values will be clinically useful when evaluating prognosis in hospitalized patients with heart failure.

Implementation of a Patient Navigator Program to Reduce 30-day Heart Failure Readmission Rate

With increasing awareness to provide personalized care our institution applied the American College of Cardiology (ACC) Patient Navigator Program to identify hospitalized heart failure (HF) patients and improve transitions and outcomes. Utilizing a Navigator Team (NT) composed of a nurse and clinical pharmacist, we delivered evidenced-based interventions and hypothesized this approach would improve identification of HF inpatients and reduce the 30-day all-cause readmission rate. Patients were followed from admission to discharge and received at least one intervention, tailored to the patient's health literacy and social needs. The 30-day all-cause readmission rate was 17.6% for the Patient Navigator Program and 25.6% for the medical center. Compared to the medical center there was a statistically significant increase in education and follow-up. For patients who received specific NT interventions of education and follow-up the readmission rate was 10.3% and 6.1% respectively. Hospital programs can easily embed a NT into existing initiatives to further reduce the readmission rate.

Clinical Research on Brain Natriuretic Peptide Guiding the Application of β1 Receptor Blocker in Patients with Moderate to Severe Heart Failure

BACKGROUND

This study aimed to explore the feasibility of guiding the application of metoprolol succinate in patients with moderate to severe heart failure (HF) through monitoring plasma brain natriuretic peptide (BNP) levels.

METHODS

A total of 195 patients with moderate to severe HF (NYHA Functional Class III to IV) were selected and randomized into two groups: an observation group and a BNP group. The groups were established to observe the clinical conditions and establish plasma BNP levels to guide the application of metoprolol succinate. The average start-up of metoprolol succinate and average dose of metoprolol succinate after one month, as well as the recurrence rate and mortality of HF during hospital stay were compared between the two groups.

RESULTS

Start-up of metoprolol succinate was shorter in the BNP group than in the observation group [(5.89 ± 1.76) d vs. (7.03 ± 2.08) d, p < 0.01], but no significant differences in recurrence rate (26.60% vs. 23.91%, p > 0.05) and mortality (6.38% vs. 5.43%, p > 0.05) of HF were observed between the two groups. The average dose of metoprolol succinate after one month was higher in the BNP group compared with that of the observation group [(47.65 ± 13.09) mg/d vs. (35.08 ± 11.08) mg/d, p < 0.01].

CONCLUSIONS

Although monitoring plasma BNP might have limited the clinical impact on the change of left ventricular ejection fraction, recurrence of HF or mortality within 1 month, it could safely facilitate early use and up-titration of the metoprolol succinate in patients with moderate to severe HF.

KEY WORDS

BNP; Heart failure; β receptor blocker.

Serum potassium decline during hospitalization for acute decompensated heart failure is a predictor of 6-month mortality, independent of N-terminal pro-B-type natriuretic peptide levels: An individual patient data analysis

BACKGROUND

Limited data exist for the role of serum potassium changes during hospitalization for acute decompensated heart failure (ADHF). The present study investigated the long-term prognostic value of potassium changes during hospitalization in patients admitted for ADHF.

METHODS

Our study is a pooled individual patient data analysis assembled from 3 prospective cohorts comprising 754 patients hospitalized for ADHF. The endpoint was all-cause mortality within 180 days after discharge. Serum potassium levels and N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels were measured at admission and at discharge.

RESULTS

A percentage decrease >15% in serum potassium levels occurred in 96 (13%) patients, and an absolute decrease of >0.7 mmol/L in serum potassium levels occurred in 85 (12%) patients; and both were predictors of poor outcome independent of admission or discharge serum potassium. After the addition of other strong predictors of mortality-a 30% change in NT-proBNP during hospitalization, discharge levels of NT-proBNP, renal markers, and other relevant clinical variables-the multivariate hazard ratio of serum potassium percentage reduction of >15% remained an independent predictor of 180-day mortality (hazard ratio 2.06, 95% CI 1.14-3.73).

CONCLUSIONS

A percentage serum potassium decline of >15% is an independent predictor of 180-day all-cause mortality on top of baseline potassium levels, NT-proBNP levels, renal variables, and other relevant clinical variables. This suggest that patients hospitalized for ADHF with a decline of >15% in serum potassium levels are at risk and thus monitoring and regulating of serum potassium level during hospitalization are needed in these patients.

Serial Measurement of Amino-Terminal Pro-B-Type Natriuretic Peptide Predicts Adverse Cardiovascular Outcome in Children With Primary Myocardial Dysfunction and Acute Decompensated Heart Failure

OBJECTIVES

In children, elevated amino-terminal pro-B-type natriuretic peptide levels are associated with impaired heart function. The predictive value of serial monitoring of amino-terminal pro-B-type natriuretic peptide levels in acute decompensated heart failure is unclear.

DESIGN

Prospective observational study.

SETTING

Single, tertiary referral pediatric critical care unit.

PATIENTS

Patients aged 0-21 years with primary myocardial dysfunction and acute decompensated heart failure.

INTERVENTIONS

Amino-terminal pro-B-type natriuretic peptide levels were obtained on enrollment, day 2, and day 7. Clinical, laboratory, and imaging data were collected on enrollment. Adverse cardiovascular outcome was defined as heart transplant, ventricular assist device placement, extracorporeal membrane oxygenation, or death at 1 year after admission. Aminoterminal pro-B-type natriuretic peptide levels and the percent change from day 0 to day 2 and day 0 to day 7 were calculated and compared between those with and without adverse cardiovascular outcome.

MEASUREMENTS AND MAIN RESULTS

Sixteen consecutive patients were enrolled. Adverse cardiovascular outcome occurred in six patients (37.5%, four heart transplant and two ventricular assist device). In patients with an adverse cardiovascular outcome, median amino-terminal pro-B-type natriuretic peptide levels at day 7 were significantly higher (7,365 vs 1,196 pg/mL; p = 0.02) and the percent decline in amino-terminal pro-B-type natriuretic peptide was significantly smaller (28% vs 73%; p = 0.02) compared with those without an adverse cardiovascular outcome. Receiver operating curve analysis revealed that a less than 55% decline in amino-terminal pro-B-type natriuretic peptide levels at day 7 had a sensitivity and specificity of 83% and 90%, respectively, in predicting an adverse cardiovascular (area under the curve, 0.86; 95% CI, 0.68-1.0; p = 0.02).

CONCLUSIONS

In conclusion, children with primary myocardial dysfunction and acute decompensated heart failure, a persistently elevated amino-terminal pro-B-type natriuretic peptide, and/or a lesser degree of decline in amino-terminal pro-B-type natriuretic peptide during the first week of presentation were strongly associated with adverse cardiovascular outcome. Serial amino-terminal pro-B-type natriuretic peptide monitoring may allow the early identification of children at risk for worse outcome.

Rationale and design of PRIMA II: A multicenter, randomized clinical trial to study the impact of in-hospital guidance for acute decompensated heart failure treatment by a predefined NT-PRoBNP target on the reduction of readmIssion and Mortality rAtes

BACKGROUND

Hospital admissions for acute decompensated heart failure (ADHF) are frequent and are accompanied by high percentages of mortality and readmissions. Brain natriuretic peptide (BNP) and the inactive N-terminal fragment of its precursor proBNP (NT-proBNP) are currently the best predictors of prognosis in heart failure (HF) patients. In the setting of chronic HF, studies that performed guidance of therapy by NT-proBNP have had only limited success. For patients with ADHF, retrospective studies have shown that a reduction in NT-proBNP of ≤30% during admission is a significant predictor of HF readmissions and mortality. These data suggest a role for NT-proBNP guidance in the setting of ADHF admissions.

STUDY DESIGN

The PRIMA II is an investigator-initiated, multicenter, randomized, controlled, prospective 2-arm trial that investigates the impact of inhospital guidance for ADHF treatment by a predefined NT-proBNP target (>30% reduction during admission) on the reduction of readmission and mortality rates within 180 days. Consenting ADHF patients with NT-proBNP levels of >1,700 ng/L are eligible. After achieving clinical stability, a total of 340 patients are randomized to either NT-proBNP-guided or conventional treatment (1:1). The primary end point is dual, that is, a composite of all-cause mortality and readmission for HF in 180 days and the number of days alive out of hospital in 180 days. Secondary end points are readmissions and/or mortality in 180 days, cost effectiveness of hospitalization days in 180 days, readmissions and mortality in 90 days, and quality of life.

CONCLUSION

The PRIMA II trial aims at providing scientific evidence for the use of NT-proBNP-guided therapy compared with conventional treatment in patients admitted for ADHF.

Single measurement of serum N-terminal pro-brain natriuretic peptide: the best predictor of long-term mortality in patients with chronic systolic heart failure

BACKGROUND

Although high serum natriuretic peptide (NP) has long been associated with mortality prediction, it was usually tested under acute heart failure (HF) conditions and periods of analysis were short. This may explain the lack of consensus when its routine measurement for mortality prediction is contemplated. Here we evaluated, at the first clinic visit of chronic systolic HF patients, the usefulness of a single serum NP assessment for long-term mortality prediction.

METHODS

In 279 consecutive patients with chronic systolic HF, serum NT-proBNP was routinely measured once during the first clinic visit. We analyzed correlations between recorded mortality and the NT-proBNP finding, along with several known clinical echocardiographic, electrocardiographic and laboratory parameters recorded at that visit.

RESULTS

During average follow-up of 34±21months 59 (21%) patients died. Serum NT-proBNP was the strongest of the tested predictors of mortality [hazard ratio 3.76, 95% Cl (1.20-11.80), p=0.008]. Nearly seven years later, mortality was still higher in patients with higher initial serum NT-proBNP (p<0.001).

CONCLUSIONS

Compared to many other traditional prognostic parameters tested at the same time, the single serum NT-proBNP finding was the strongest predictor of long-term mortality. These results may justify its routine use for this purpose.

Plasma NT pro-BNP, hs-CRP and big-ET levels at admission as prognostic markers of survival in hospitalized patients with dilated cardiomyopathy: a single-center cohort study

Background

Circulating N-terminal pro-B-type natriuretic peptide (NT pro-BNP), high- sensitivity C-reactive protein (hs-CRP) and big endothelin (big-ET) have been shown to be increased in heart failure and to contribute to both hemodynamic deterioration and cardiovascular remodeling. Here, we examined the prognostic value of the three neurohormones at admission in a population of hospitalized patients with dilated cardiomyopathy (DCM).

Methods and results

This cohort study was undertaken in 622 hospitalized patients with DCM in Fuwai Hospital from January 2005 to September 2011 (female 26.5%, 51.4 ± 14.6 years old). Standard demographics, echocardiography and routine blood samples were obtained shortly after admission. NT pro-BNP, hs-CRP and big-ET were measured, and their concentrations in relation to all-cause mortality were assessed through a mean follow-up of 2.6 ± 1.6 years. Kaplan-Meier curves showed that the all-cause mortality rates were higher in patients with NT pro-BNP > 2247 pmol/L compared to patients with NT pro-BNP < 2247 pmol/L (11.9% vs 34.8%, log-rank χ² = 35.588, P < 0.001), in patients with hs-CRP > 3.90 mg/L compared to patients with hs-CRP < 3.90 mg/L (12.8% vs 33.6%, log-rank χ² = 39.662, P < 0.001) and in patients with big-ET > 0.95 pmol/L compared to patients with big-ET <0.95 pmol/L (12.5% vs 31.0%, log-rank χ² = 17.890, P < 0.001). High circulating concentrations of NT pro-BNP (HR 2.217, 95% CI 1.015-4.846, P = 0.046) and hs-CRP (HR 1.922, 95% CI 1.236-2.988, P = 0.004), but not big-ET, in addition to left atrial diameter and fasting blood glucose, were independent predictors of the outcome defined as all-cause mortality.

Conclusions

In a large population of patients with DCM, the circulating concentrations of NT pro-BNP and hs-CRP, but not big-ET, were independent markers of all-cause mortality.

A novel discharge risk model for patients hospitalised for acute decompensated heart failure incorporating N-terminal pro-B-type natriuretic peptide levels: a European coLlaboration on Acute decompeNsated Heart Failure: ELAN-HF Score

BACKGROUND

Models to stratify risk for patients hospitalised for acute decompensated heart failure (ADHF) do not include the change in N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels during hospitalisation.

OBJECTIVE

The aim of our study was to develop a simple yet robust discharge prognostication score including NT-proBNP for this notorious high-risk population.

DESIGN

Individual patient data meta-analyses of prospective cohort studies.

SETTING

Seven prospective cohorts with in total 1301 patients.

PATIENTS

Our study population was assembled from the seven studies by selecting those patients admitted because of clinically validated ADHF, discharged alive, and NT-proBNP measurements available at admission and at discharge.

MAIN OUTCOME MEASURES

The endpoints studied were all-cause mortality and a composite of all-cause mortality and/or first readmission for cardiovascular reason within 180 days after discharge.

RESULTS

The model that incorporated NT-proBNP levels at discharge as well as the changes in NT-proBNP during hospitalisation in addition to age ≥75 years, peripheral oedema, systolic blood pressure ≤115 mm Hg, hyponatremia at admission, serum urea of ≥15 mmol/L and New York Heart Association (NYHA) class at discharge, yielded the best C-statistic (area under the curve, 0.78, 95% CI 0.74 to 0.82). The addition of NT-proBNP to a reference model significantly improved prediction of mortality as shown by the net reclassification improvement (62%, p<0.001). A simplified model was obtained from the final Cox regression model by assigning weights to individual risk markers proportional to their relative risks. The risk score we designed identified four clinically significant subgroups. The pattern of increasing event rates with increasing score was confirmed in the validation group (BOT-AcuteHF, n=325, p<0.001).

CONCLUSIONS

In patients hospitalised for ADHF, the addition of the discharge NT-proBNP values as well as the change in NT-proBNP to known risk markers, generates a relatively simple yet robust discharge risk score that importantly improves the prediction of adverse events.