N-Terminal Pro–B-Type Natriuretic Peptide–Guided, Intensive Patient Management in Addition to Multidisciplinary Care in Chronic Heart FailureA 3-Arm, Prospective, Randomized Pilot Study
Rudolf Berger, MD*,*,
Deddo Moertl, MD*,
Sieglinde Peter, RN*,
Roozbeh Ahmadi, MD*,
Martin Huelsmann, MD*,
Susan Yamuti, RN ,
Brunhilde Wagner, MD and
Richard Pacher, MD*
* Department of Cardiology, Medical University of Vienna, Vienna, Austria
Department of Cardiology, Hospital of Hietzing, Vienna, Austria
Department of Cardiology, Hospital Sozialmedizinisches Zentrum Ost, Vienna, Austria
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Figure 1 Recommendations for BM
N-terminal pro–B-type natriuretic peptide (NT-proBNP) levels were used to determine the intensity of care during medical optimization, thereby selecting high-risk patients (NT-proBNP >2,200 pg/ml) for intensified care by heart failure (HF) specialists and discharging them from this care in case of a decrease of NT-proBNP <2,200 pg/ml after 3 or 6 months. In high-risk patients, the course of NT-proBNP levels was used in addition to other clinical and laboratory parameters for integrated clinical management (e.g., adaptation of diuretic regimen, speed of dose-increase of neurohormonal antagonists, schedule of visits). *Increase of angiotensin-converting enzyme inhibitor (ACE-I)/angiotensin receptor blocker (ARB) or beta-blocker only in the absence of: 1) symptomatic hypotension; 2) significant increase of serum creatinine (>0.3 mg/dl or >50% of serum creatinine >2.5 mg/dl); and 3) for beta-blocker, heart rate  60 beats/min. BM = N-terminal pro–B-type natriuretic peptide-guided, intensive patient management; BP = blood pressure; iv = intravenous; MC = multidisciplinary care; NYHA = New York Heart Association; RAAS = renin-angiotensin-aldosterone system.
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Figure 2 Consort Diagram
A total of 462 patients were screened for the study, of which 21 patients never met eligibility criteria. Of 441 eligible patients, 163 refused to participate, and the remaining 278 patients were randomized to BM (n = 92), MC (n = 96), and usual care (n = 90). Abbreviations as in Figure 1.
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Figure 3 Effect of UC, MC, and BM on Heart Failure Therapy
The proportion of triple therapy (spironolactone and 50% of the target dose of an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker and of a beta-blocker) was similar among groups at baseline, but was higher in the BM group versus the MC group, and higher in the MC versus the usual care (UC) group at follow-up. Abbreviations as in Figure 1.
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Figure 4 Baseline and Follow-Up Values of NT-ProBNP
Box plot with mean [+], median, lower and upper quartiles, and 95% confidence intervals: the decrease of NT-proBNP levels from discharge to follow-up was more pronounced in the BM group than in the MC group. No decrease was observed in the UC group. Abbreviations as in Figures 1 and 3.
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Figure 5 Survival Without HF Hospitalization
Up to 18 months, the combined end point of death or heart failure (HF) hospitalization was lower in the BM (37%) versus MC group (50%; p < 0.05) and in the MC versus UC group (65%; p = 0.04). Abbreviations as in Figures 1 and 3.
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