Page 96 - Biomarkers for risk stratification and guidance in heart failure

Which heart failure patients profit from natriuretic peptide-guided therapy?
Moreover, results on HF hospitalizations were not influenced by comorbidities,
arguing against lack of therapy intensification as main reason for this finding. In
addition, diagnosis of comorbidities was not based on specific testing, but rather
on medical records. However, this is common practice and represents clinical
care in patients with HF. Moreover, we do not have sufficient data in the majority
of the studies to calculate an established co-morbidity index (e.g. Charlson
index), although we included the most common comorbidities in HF patients.
In addition, this is a post-hoc analysis best regarded as hypothesis-generating.
Finally, the number of patients was not sufficiently large to address all subgroup
analyses with sufficient power. This is particularly true for HFpEF patients, in
which the number of events was small. In addition, we used multiple testing and
statistical tests for interactions are not powerful. This prevented us from doing in-
depth analysis which factors may explain the different response between HFrEF 4 and HFpEF. Finally, we do not have sufficient data to test if uptitration differed
between these two groups. However, in the study including most HFpEF patients, uptitration of medication did not differ between the two groups, but reduction in NT-proBNP levels was less in HFpEF patients.17 Thus, interpretation of our findings must be done with caution, particularly in patients with HFpEF.
Conclusion
Our individual patient data meta-analysis indicates that NT-proBNP-guided therapy may be helpful in HFrEF but not in HFpEF. Our results support the notion that HFrEF and HFpEF are two distinct entities. Moreover, the effects of intensifying HF treatment seem to be strongly influenced by comorbidities and not by age per se, but further prospective studies are required to test these hypotheses.
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