CORRESPONDENCE: LETTER TO THE EDITOR
Plasma Brain Natriuretic Peptide-Guided Therapy Not Yet Justified
Uta C. Hoppe, MD*
* Department of Internal Medicine III, University of Cologne, Kerpener Str. 62, 50937 Cologne, Germany (Email: uta.hoppe{at}uni-koeln.de).
A recent study by Jourdain et al. (1) published in the Journal suggests that a brain natriuretic peptide (BNP)-guided therapeutic strategy was superior to a clinically guided approach in patients with chronic heart failure (CHF). A total of 200 New York Heart Association functional class II to III patients considered optimally treated by CHF specialists were randomized to medical treatment according to current guidelines (2) or a goal of decreasing BNP plasma levels to <100 pg/ml. During a median follow-up of 15 months, significantly fewer patients in the BNP group reached the combined end point of CHF-related death or hospital stay for CHF, mainly as the result of a reduced hospitalization rate. At baseline in both groups, a similar percentage of patients received angiotensin-converting enzyme inhibitors (ACEIs) and beta-blockers with a comparable percentage of recommended doses. At the end of the first 3 months, however, mean dosages of ACEIs and beta-blockers were significantly greater in the BNP group, which was considered to be the reason for the more favorable outcome of the BNP group.
These results are consistent with a previous smaller study suggesting superiority of N-terminal prohormone brain natriuretic peptide-guided treatment to clinically guided therapy (3). Although in that previous study beta-blockers were not yet generally prescribed, patients with CHF also received markedly lower dosages of ACEIs in the clinical group than in the BNP group.
However, in both studies, it does not appear conclusive why a patient who got blood drawn for BNP assessment should better tolerate up-titration of heart failure medication to target dosages. Thus, a considerable subset of patients in the clinical group "guided by guidelines" appears not to have been treated according to target dosages recommended in these guidelines.
Therefore, the study by Jourdain et al. (1) indicates that, for whatever reason, doctors are more likely to adhere to a target range of a surrogate parameter than to evidence-based recommendations of pharmacological doses and supports consequent up-titration to target doses in all CHF patients independent of BNP levels. To possibly support BNP-guided dosing, randomized trials are required assessing: 1) whether it is safe to keep patients on a low/moderate dose of ACEIs and beta-blockers after reaching normal BNP levels versus further up-titration to target dosages according to guidelines; and 2) whether patients with persistent elevated BNP levels despite target doses of ACEIs and beta-blockers benefit from dose increases beyond current target dosages if tolerated. In conclusion, currently available data do not yet justify a differential therapeutic strategy guided by BNP and do not support the superiority of BNP-guided treatment if doctors would more consequently adhere to dose recommendations of guidelines.
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References
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- Jourdain P, Jondeau G, Funck F, et al. Plasma brain natriuretic peptide-guided therapy to improve outcome in heart failure: the STARS-BNP multicenter study J Am Coll Cardiol 2007;49:1733-1739.[Abstract/Free Full Text]
- Swedberg K, Cleland J, Dargie H, et al. Guidelines for the diagnosis and treatment of chronic heart failure: executive summary (update 2005): the Task Force for the Diagnosis and Treatment of Chronic Heart Failure of the European Society of Cardiology Eur Heart J 2005;26:1115-1140.[Free Full Text]
- Troughton RW, Frampton CM, Yandle TG, Espiner EA, Nicholls MG, Richards AM. Treatment of heart failure guided by plasma aminoterminal brain natriuretic peptide (N-BNP) concentrations Lancet 2000;355:1126-1130.[CrossRef][ISI][Medline]
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J. Am. Coll. Cardiol. 2007 50: 2098-2099.
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