Page 159 - Biomarkers for risk stratification and guidance in heart failure

Chapter 7
7.4 NATRIURETIC PEPTIDE-GUIDED THERAPY IN DAILY PRACTICE.
Enough evidence?
Although multiple meta-analyses demonstrate natriuretic peptide-guided therapy, at least in HFrEF patients without many comorbidities, leads to improved outcome,57-61 current European guidelines still do not support such an approach.67 The American guidelines recommend use natriuretic peptide-guided therapy for titration of evidence based HF medication in clinically euvolemic patients, although they claim that usefulness to reduce hospitalization or mortality in patients with HF is not well established.73 Question remains why the guidelines have been reluctant to recommend usage of natriuretic peptides to guide therapy. As BNP and NT-proBNP are used as routine measurements in the diagnosis of heart failure, these peptides are widely assessable, and results are available within one hour after measurement. However, before a natriuretic peptide-guided treatment algorithm can be introduced in daily practice, the effectiveness of such approach should be confirmed in at least one, sufficiently powered, randomized controlled trial. A large multicenter trial on natriuretic peptide-guided therapy with an estimated inclusion rate of 1,100 patients is currently on its way (GUIDE-IT).74 Primary results are to be expected in 2018. Furthermore, the treatment strategy has to be proven cost-effective. Unfortunately, there are only few published reports on the cost-effectiveness of using natriuretic peptides to guide therapy.75-77 The largest cost-effectiveness study conducted among patients included in the TIME-CHF trial demonstrated that NT-proBNP-guided therapy has a high probability of being cost-effective, saving almost $3,000 per patient.77 However, the net cost reduction was mainly caused by a reduction in residence cost and it is not clear whether this effect is solely contributable to NT-proBNP-guided therapy. The previously mentioned GUIDE-IT trial will contain a cost-effectiveness analysis; results of this trial need to be awaited before any firm conclusions about cost-effectiveness can be drawn.
What natriuretic peptide target value should be implemented?
Furthermore it should become more clear what natriuretic peptide target value should be implemented. As mentioned before, no uniform treatment target was used in the previously published trials. However, the majority of studies performed used a fixed (NT-pro) BNP target value (table 1). Moreover, all studies demonstrating any positive effect of natriuretic peptide-guided therapy
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