Page 118 - Biomarkers for risk stratification and guidance in heart failure

Serial NT-proBNP measurements during and early after HF admission.
concentration might have actually been an early - subclinical - sign of worsening HF. Indeed, in line with this reasoning, the only study assessing short term biologic variability of NT-proBNP with a follow-up period of 6 months showed the lowest RVC, 23%.19
Composite NT-proBNP Score and Implications for Clinical Practice
A composite NT-proBNP score that combines inpatient change in NT-proBNP
with early outpatient change and the absolute NT-proBNP concentration 1 month
after hospital discharge identified HF patients at very low (1.6%), intermediate (8.5%-16.9%), and high (38.6%) risk for early readmission or mortality. The
prognostic impact remained after one year follow-up. The composite NT-proBNP
score has been designed to illustrate the incremental information from the
different NT-proBNP measurements. Because the cutpoints for the NT-proBNP
parameters were defined by the distribution within the PRIMA study, application
of these cutpoints cannot be used in clinical practice until validation analysis
has been performed. Furthermore, whether knowledge of the individual risk
for events would lead to reduction in morbidity and mortality remains to be 5 assessed by future trials and cannot be answered by the present study. However,
it seems plausible that patients at highest risk for events might benefit most from intensified outpatient follow-up in combination with increased prescription of evidence-based HF medication, such as angiotensin-converting enzyme 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.20,21 The BATTLESCARRED (NT-proBNP-Assisted Treatment to Lessen Serial Cardiac Readmissions and Death) trial, eg, demonstrated 1-year mortality being lower in the intensified outpatient treatment group (9.1%) compared with usual care (18.9%; P= .03).21 Furthermore, in all 4 studies demonstrating a positive effect of natriuretic peptide-guided therapy,20,22-24 a marked increase in evidence-based HF medication was seen in the natriuretic peptide-guided 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
117