Page 161 - Biomarkers for risk stratification and guidance in heart failure

Chapter 7
high was mostly left at the discretion of the treating physician. As treatment of HF is complex and multifactorial, it is impossible to provide fixed HF treatment algorithms. However, it seems plausible that patients at highest risk for events (i.e. with increased or increasing natriuretic peptide levels) might benefit the most from intensified outpatient follow-up in combination with increased prescription of evidence-based HF medication, such as ACE-inhibitors, beta-blockers, and aldosterone antagonists. Recent trials assessing the effect of natriuretic peptide- guided therapy in HF that randomized patients into 3 treatment arms (ie, regular outpatient care vs intensified outpatient care with or without knowledge of natriuretic peptide concentration) have shown that intensified outpatient care leads to a decrease in HF related readmissions and mortality compared to usual care.47,48 The BATTLESCARRED trial for example demonstrated 1-year mortality being lower in the intensified outpatient treatment group (9,1%) compared with usual care (18.9%, P=0.03).47 Furthermore, in all 4 studies demonstrating a reduction in primary endpoint by natriuretic peptide-guided therapy44,46,48,53 a marked increase in evidence based HF medication was seen in the natriuretic peptide-guided therapy arm compared with the usual care arm. Thus, intensified treatment in combination with increase in evidence-based HF medication appears to lead to better outcome. In 2 of these 4 trials, patients allocated to the NT- proBNP-guided therapy arm had fewer prescription of loop diuretics compared with usual care management.48,53 In the PRIMA study, which failed to demonstrate a significant reduction in endpoints by NT-proBNP-guided therapy, outpatient elevated NT-proBNP levels led most frequently to an increase in diuretic dosage (>40%).51
Given the association between loop diuretics and worsening of renal function, neurohumoral activation, and adverse outcome in HF,82 the use of diuretics is recommended to be limited to achieve and maintain an euvolemic state with the lowest achievable dose.
Therefore it can be hypothesized that patients at lowest risk (i.e. stable or decreasing NT-proBNP levels below 1,000 pg/ml) do not need intensified outpatient follow-up in dedicated HF clinics. In contrast, patients at highest risk for events (increasing NT-proBNP levels, or levels above 1,000 pg/ml) indeed should receive intensified outpatient follow-up. If NT-proBNP levels increase, or are stable above 1,000 pg/ml it should be aimed to increase evidence based HF medication if the patient is clinically euvolaemic. However, if a patient is clinically decompensated diuretics should be increased first. If NT-proBNP levels are above
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