Page 158 - Biomarkers for risk stratification and guidance in heart failure

that increasing HF therapy upon an elevated (NT-pro) BNP level does not lead to improved outcome in HFpEF patients. Our findings support current treatment recommendations for HFpEF which are restricted to treatment of comorbidities and symptoms.67
Natriuretic peptide-guided therapy in HFrEF
Our results call into question the belief that (NT-pro)BNP-guided HFrEF care
is limited simply by age. We hypothesize that comorbidities influence the
treatment response to HF medication. It is well known that comorbidities
negatively influence prognosis in HF patients.68 Moreover, there are numerous
studies showing the potential risk of drug-drug interactions leading to adverse
effects with the increasing number of comorbidities and as a consequence
increasing number of prescribed drugs.69 However it is less clear if this may result
in less beneficial effects of HF specific medication. On the other hand, there is
a direct correlation between the number of medications, number of daily doses
and dosage adjustments, and the rate of nonadherence to pharmacological
therapies.70 A poor compliance to therapy has been linked to a poorer outcome
and higher risk of HF decompensation, hospitalization and death.71 In fact,
full understanding of how multiple comorbidities in “real world” HF patients
affect effectiveness of proven therapies for HF is lacking. In addition to a better understanding of the effects of (NT-pro)BNP-guided therapy in HF, our results
shed new light on HF treatment in general. Only a minority of the real-life HF
patients fulfill the enrolment criteria of landmark HF trials72 because patients
with comorbidities have often been excluded. In contrast, most of the (NT-pro)
BNP-guided HF trials did not have similarly restrictive inclusion criteria, resulting 7 in recruitment of more “real world” patients. Our results on comorbidities might
partially explain why in daily practice, recommended therapies are often not used in adequate doses. Further studies on the effect of HF medication in patients with combined comorbidities and the feasibility and wisdom of titrating to currently recommended target doses in such patients are utterly needed.
General Discussion
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