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J Am Coll Cardiol, 2007; 49:1733-1739, doi:10.1016/j.jacc.2006.10.081 (Published online 30 March 2007).
© 2007 by the American College of Cardiology Foundation
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EXPEDITED REVIEW

Plasma Brain Natriuretic Peptide-Guided Therapy to Improve Outcome in Heart Failure

The STARS-BNP Multicenter Study

Patrick Jourdain, MD*,{dagger},{ddagger},*, Guillaume Jondeau, MD, PhD§, François Funck, MD{ddagger}, Pascal Gueffet, MD||, Alain Le Helloco, MD, Erwan Donal, MD, Jean F. Aupetit, MD#, Marie C. Aumont, MD§, Michel Galinier, MD, PhD**, Jean C. Eicher, MD{dagger}{dagger}, Alain Cohen-Solal, MD, PhD{ddagger}{ddagger} and Yves Juillière, MD, PhD§§

* René Descartes University, Paris, France
{dagger} Georges Pompidou Hospital, Paris, France
§ Department of Cardiology, Bichat University Hospital, Paris, France
{ddagger}{ddagger} Department of Cardiology, Centre Hospitalier Universitaire de Lariboisière, Paris, France
{ddagger} Hospitalier de Rene Dubos, Pontoise, France
|| Centre Hospitalier Universitaire de Nantes, Nantes, France
Centre Hospitalier Universitaire de Rennes, Rennes, France
# Hopital Saint Luc Lyon, Lyon, France
** Department of Cardiology, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
{dagger}{dagger} Centre Hospitalier Universitaire de Dijon, Dijon, France
§§ Department of Cardiology, Centre Hospitalier Universitaire de Vandoeuvre Les Nancy, Vandoeuvre Les Nancy, France

Manuscript received September 12, 2006; revised manuscript received October 10, 2006, accepted October 22, 2006.

* Reprint requests and correspondence: Dr. Patrick Jourdain, Hopital de Pontoise, CH Rene Dubos, Heart Failure Department, 6 Avenue de France, Pontoise, 95301 France. (Email: patrick.jourdain{at}ch-pontoise.fr).

Objectives: The aim of this multicenter study was to evaluate the prognostic impact of a therapeutic strategy using plasma brain natriuretic peptide (BNP) levels.

Background: The prognosis of chronic heart failure (CHF) remains poor, even among patients treated in specialized departments.

Methods: A total of 220 New York Heart Association functional class II to III patients considered optimally treated with angiotensin-converting enzyme inhibitors (ACEIs), beta-blockers, and diuretics by CHF specialists were randomized to medical treatment according to either current guidelines (clinical group) or a goal of decreasing BNP plasma levels <100 pg/ml (BNP group). Outpatient visits were scheduled every month for 3 months, then every 3 months. The primary combined end point was CHF-related death or hospital stay for CHF.

Results: Both groups were similar for baseline clinical and biological characteristics. Left ventricular ejection fraction was slightly lower in the BNP group than in the clinical group (29.9 ± 7.7% vs. 31.8 ± 8.4%, p = 0.05). At the end of the first 3 months, all types of drugs were changed more frequently in the BNP group. Mean dosages of ACEIs and beta-blockers were significantly higher in the BNP group (p < 0.05), whereas the mean increase in furosemide dosage was similar in both groups. During follow-up (median 15 months), significantly fewer patients reached the combined end point in the BNP group (24% vs. 52%, p < 0.001).

Conclusions: In optimally treated CHF patients, a BNP-guided strategy reduced the risk of CHF-related death or hospital stay for CHF. The result was mainly obtained through an increase in ACEI and beta-blocker dosages.

Abbreviations and Acronyms
  ACEI = angiotensin-converting enzyme inhibitor
  ARB = angiotensin II-receptor blockers
  BNP = brain natriuretic peptide
  CHF = chronic heart failure
  LVEF = left ventricular ejection fraction
  NYHA = New York Heart Association




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Authors/Task Force Members, K. Dickstein, A. Cohen-Solal, G. Filippatos, J. J.V. McMurray, P. Ponikowski, P. A. Poole-Wilson, A. Stromberg, D. J. van Veldhuisen, D. Atar, et al.
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2008: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2008 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association of the ESC (HFA) and endorsed by the European Society of Intensive Care Medicine (ESICM)
Eur J Heart Fail, October 1, 2008; 10(10): 933 - 989.
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 J Am Coll CardiolHome page
S. Masson, R. Latini, I. S. Anand, S. Barlera, L. Angelici, T. Vago, G. Tognoni, J. N. Cohn, and for the Val-HeFT Investigators
Prognostic Value of Changes in N-Terminal Pro-Brain Natriuretic Peptide in Val-HeFT (Valsartan Heart Failure Trial)
J. Am. Coll. Cardiol., September 16, 2008; 52(12): 997 - 1003.
[Abstract] [Full Text] [PDF]

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 Eur Heart JHome page
D. Kelly, S. Q. Khan, M. Thompson, G. Cockerill, L. L. Ng, N. Samani, and I. B. Squire
Plasma tissue inhibitor of metalloproteinase-1 and matrix metalloproteinase-9: novel indicators of left ventricular remodelling and prognosis after acute myocardial infarction
Eur. Heart J., September 1, 2008; 29(17): 2116 - 2124.
[Abstract] [Full Text] [PDF]

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 Eur J Heart FailHome page
A. Maisel, C. Mueller, K. Adams Jr., S. D. Anker, N. Aspromonte, J. G.F. Cleland, A. Cohen-Solal, U. Dahlstrom, A. DeMaria, S. Di Somma, et al.
State of the art: Using natriuretic peptide levels in clinical practice
Eur J Heart Fail, September 1, 2008; 10(9): 824 - 839.
[Abstract] [Full Text] [PDF]

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 J. Am. Soc. Nephrol.Home page
A. Y.-M. Wang and K.-N. Lai
Use of Cardiac Biomarkers in End-Stage Renal Disease
J. Am. Soc. Nephrol., September 1, 2008; 19(9): 1643 - 1652.
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 J. Thorac. Cardiovasc. Surg.Home page
A. A. Fox, S. K. Shernan, C. D. Collard, K.-Y. Liu, S. F. Aranki, S. M. DeSantis, P. Jarolim, and S. C. Body
Preoperative B-type natriuretic peptide is as independent predictor of ventricular dysfunction and mortality after primary coronary artery bypass grafting.
J. Thorac. Cardiovasc. Surg., August 1, 2008; 136(2): 452 - 461.
[Abstract] [Full Text] [PDF]

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 Eur J Heart FailHome page
V. M.A. Conraads, C. De Maeyer, P. Beckers, N. Possemiers, M. Martin, V. Van Hoof, and C. J. Vrints
Exercise-induced biphasic increase in circulating NT-proBNP levels in patients with chronic heart failure
Eur J Heart Fail, August 1, 2008; 10(8): 793 - 795.
[Abstract] [Full Text] [PDF]

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 J Am Coll CardiolHome page
M. Nishii, T. Inomata, H. Takehana, T. Naruke, T. Yanagisawa, M. Moriguchi, S. Takeda, and T. Izumi
Prognostic Utility of B-Type Natriuretic Peptide Assessment in Stable Low-Risk Outpatients With Nonischemic Cardiomyopathy After Decompensated Heart Failure
J. Am. Coll. Cardiol., June 17, 2008; 51(24): 2329 - 2335.
[Abstract] [Full Text] [PDF]

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 J Am Coll CardiolHome page
R. M. Mills
Learning to Use a Biomarker: More About B-Type Natriuretic Peptide
J. Am. Coll. Cardiol., June 17, 2008; 51(24): 2336 - 2338.
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 Eur J Heart FailHome page
O. Oldenburg, A. Schmidt, B. Lamp, T. Bitter, B. G. Muntean, C. Langer, and D. Horstkotte
Adaptive servoventilation improves cardiac function in patients with chronic heart failure and Cheyne-Stokes respiration
Eur J Heart Fail, June 1, 2008; 10(6): 581 - 586.
[Abstract] [Full Text] [PDF]

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 Circ Heart FailHome page
J. J.V. McMurray, B. Pitt, R. Latini, A. P. Maggioni, S. D. Solomon, D. L. Keefe, J. Ford, A. Verma, J. Lewsey, and for the Aliskiren Observation of Heart Failure Tre
Effects of the Oral Direct Renin Inhibitor Aliskiren in Patients With Symptomatic Heart Failure
Circ Heart Fail, May 1, 2008; 1(1): 17 - 24.
[Abstract] [Full Text] [PDF]

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 HeartHome page
G. W Yip
B-type natriuretic peptide: a treatment, not a diagnostic marker
Heart, May 1, 2008; 94(5): 542 - 544.
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 Eur Heart JHome page
I. Squire
Assessing prognosis in heart failure: you can see a lot if you look, but more if you look again ... ... ...
Eur. Heart J., April 2, 2008; 29(8): 959 - 960.
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 Eur Heart JHome page
D. A. Pascual-Figal, M. Domingo, T. Casas, I. Gich, J. Ordonez-Llanos, P. Martinez, J. Cinca, M. Valdes, J. L. Januzzi, and A. Bayes-Genis
Usefulness of clinical and NT-proBNP monitoring for prognostic guidance in destabilized heart failure outpatients
Eur. Heart J., April 2, 2008; 29(8): 1011 - 1018.
[Abstract] [Full Text] [PDF]

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 J Am Coll CardiolHome page
J. R. Teerlink
Learning the Points of COMPASS-HF: Assessing Implantable Hemodynamic Monitoring in Heart Failure Patients
J. Am. Coll. Cardiol., March 18, 2008; 51(11): 1080 - 1082.
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 J Am Coll CardiolHome page
L. B. Daniels and A. S. Maisel
Natriuretic Peptides
J. Am. Coll. Cardiol., December 18, 2007; 50(25): 2357 - 2368.
[Abstract] [Full Text] [PDF]

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 J Am Coll CardiolHome page
P. Jourdain, G. Jondeau, and Y. Juilliere
Reply
J. Am. Coll. Cardiol., November 20, 2007; 50(21): 2098 - 2099.
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 J Am Coll CardiolHome page
U. C. Hoppe
Plasma Brain Natriuretic Peptide-Guided Therapy Not Yet Justified
J. Am. Coll. Cardiol., November 20, 2007; 50(21): 2097 - 2098.
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 J Am Coll CardiolHome page
A. Maisel
Biomarkers in Heart Failure: Does Prognostic Utility Translate to Clinical Futility?
J. Am. Coll. Cardiol., September 11, 2007; 50(11): 1061 - 1063.
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 CirculationHome page
W.H. Wilson Tang, G. S. Francis, D. A. Morrow, L. K. Newby, C. P. Cannon, R. L. Jesse, A. B. Storrow, R. H. Christenson, COMMITTEE MEMBERS, R. H. Christenson, et al.
National Academy of Clinical Biochemistry Laboratory Medicine Practice Guidelines: Clinical Utilization of Cardiac Biomarker Testing in Heart Failure
Circulation, July 31, 2007; 116(5): e99 - e109.
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