Identification and guided treatment of ventricular dysfunction in general practice using blood B-type natriuretic peptide

Mant, David; Hobbs, FD Richard; Glasziou, Paul; Wright, Lucy; Hare, R; Perera, Rafael; Price, Christopher; Cowie, Martin R.

doi:10.3399/bjgp08x299209

Cited by 11 publications

(7 citation statements)

References 19 publications

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“…A previous uncontrolled study in primary care patients with ischaemic heart disease or diabetes and BNP >150 ng/L showed the potential to reduce BNP by increasing the use of CV medication 19. However, these patients did not have diagnosed CHF, only 14% had EF <40%, and 30% were asymptomatic.…”

Section: Discussionmentioning

confidence: 93%

Improved pharmacological therapy of chronic heart failure in primary care: a randomized Study of NT‐proBNP Guided Management of Heart Failure – SIGNAL‐HF (Swedish Intervention study – Guidelines and NT‐proBNP AnaLysis in Heart Failure)

Persson

Erntell

Eriksson

et al. 2010

European J of Heart Fail

128

129

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AimsTreatment of chronic heart failure (CHF) guided by natriuretic peptides has been studied in clinical trials with conflicting results. The aim of this study was to investigate if N-terminal pro-B-type natriuretic peptide (NT-proBNP)-guided therapy in symptomatic heart failure patients in primary care would improve clinical outcomes over and above treatment according to guidelines. Methods and resultsSIGNAL-HF was a 9 month, randomized, single-blind, parallel group study in patients with CHF in NYHA class II -IV, ejection fraction (EF) ,50% and elevated NT-proBNP levels (males .800, females .1000 ng/L). All investigators underwent a pre-study educational programme about current CHF guidelines. A control group managed by nontrained investigators was considered not possible for ethical and practical reasons. Patients were randomized to structured treatment of CHF according to guidelines with or without NT-proBNP monitoring. The choice and dose of therapy for CHF was at the investigator's discretion. The primary outcome variable was the composite endpoint of days alive, days out of hospital, and symptom score from the Kansas City Cardiomyopathy Questionnaire.In all, 252 patients were randomized. The allocation groups were well balanced with regards to age, NT-proBNP, and EF. Treatment doses of beta-blockers and blockers of the renin -angiotensin-aldosterone system were markedly increased towards target doses and to a similar degree in both groups. There were no differences between the groups concerning either the primary endpoint (P ¼ 0.28) or its components [cardiovascular (CV) death, P ¼ 0.93; CV hospitalization, P ¼ 0.88; or symptom score, P ¼ 0.28]. ConclusionNT-proBNP-guided CHF treatment did not result in important improvements in clinical outcomes in patients with CHF in primary care above and beyond what could be achieved by education and structured CHF treatment according to guidelines.--

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Section: Discussionmentioning

confidence: 93%

Improved pharmacological therapy of chronic heart failure in primary care: a randomized Study of NT‐proBNP Guided Management of Heart Failure – SIGNAL‐HF (Swedish Intervention study – Guidelines and NT‐proBNP AnaLysis in Heart Failure)

Persson

Erntell

Eriksson

et al. 2010

European J of Heart Fail

128

129

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“…24 Current guidance on choice of beta-blockers needs updating and it is likely, based on the available evidence, that use of a recommended beta-blocker is preferable. 29,30 Inequity. Lower recommended beta-blocker utilisation was found among older people, women, and those living in areas of deprivation, independent of any effect of practice on treatment and after adjustment for the key contraindications of COPD and asthma.…”

Section: Implications For Clinical Practice and Future Researchmentioning

confidence: 99%

Trends and inequities in beta-blocker prescribing for heart failure

Shah

Carey²,

DeWilde³

et al. 2008

Br J Gen Pract

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Treatment with specific beta-blockers reduces mortality and hospitalisation in heart failure. AimTo describe trends and inequities in beta-blocker prescribing for heart failure. Design of studyRepeated cross-sectional analysis of a nationally representative primary care database (DIN-LINK). SettingA total of 152 UK general practices. MethodPrescribing of beta-blockers between 2000 and 2005 was examined among a yearly average of 7294 patients aged ≥50 years who had actively managed heart failure -defined as a recorded diagnosis of heart failure and two prescriptions of an angiotensinconverting enzyme inhibitor or angiotensin receptor blocker during the calendar year. The main outcome was the prescription of a guideline-recommended beta-blocker (bisoprolol, carvedilol, metoprolol, or nebivolol) in the year. Determinants of beta-blocker prescribing were analysed using logistic regression. ResultsBetween 2000 and 2005, age-adjusted use of recommended beta-blockers rose from 6.1% to 27.0% in men, and from 4.2% to 21.5% in women. In 2005, younger patients were more likely to be treated; the fully adjusted odds ratio was 4.83 (95% confidence interval = 3.78 to 6.17) for patients aged 60-64 years compared with those aged 85 years. Women and patients living in areas of socioeconomic deprivation were less likely to be treated. In 2005, in addition to treatment with guideline-recommended beta-blockers, a further 11.7% of men and 12.5% of women were prescribed other beta-blockers. ConclusionRecommended beta-blocker use has risen in the UK but remains low and inequitable, with many patients still treated with beta-blockers that are not recommended in guidelines. This suggests further improvements in prescribing are still possible.

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“… 45 A recent prospective study involving 1918 stable asymptomatic patients suggested that simple medication switch involving mostly one clinic visit can lead to BNP reduction associated with 13% potential relative reduction in mortality. 46 This study also suggested that further up titration beyond one clinic visit is much less cost-effective in asymptomatic patients. 46 Therefore, a cost-effective perioperative BNP-guided therapy in stable patients should aim to limit preoperative medication titration to no more than one extra clinic visits beyond the current standard of care.…”

Section: Introductionmentioning

confidence: 76%

“… 46 This study also suggested that further up titration beyond one clinic visit is much less cost-effective in asymptomatic patients. 46 Therefore, a cost-effective perioperative BNP-guided therapy in stable patients should aim to limit preoperative medication titration to no more than one extra clinic visits beyond the current standard of care. It has been proposed to start BNP-guided therapy for preoperative medical optimisation 4–5 weeks before surgery.…”

Section: Introductionmentioning

confidence: 76%

B-type natriuretic peptide-guided therapy for perioperative medicine?

Shang

2014

Open Heart

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The recent guideline from the European Society of Cardiology and European Society of Anesthesiology recommended the use of B-type natriuretic peptide (BNP) as preoperative testing for high-risk cardiac patients undergoing non-cardiac surgery. In this article, the potential benefits, risks and details for implementing BNP testing in perioperative medicine are discussed. Review of four related lines of research including the use of BNP test for preoperative prognosis, BNP test for screening asymptomatic heart failure, BNP as prognostic test in asymptomatic, non-heart failure patients and using BNP for detecting silent myocardial ischaemia showed converging cut-off levels of BNP for risk stratification. BNP has better OR and relative risk in comparison with Revised Cardiac Risk Index (RCRI) in predicting perioperative cardiac risk. BNP-guided therapy can be low risk based on current evidence on non-surgical patients, including treating asymptomatic patients without heart failure to prevent cardiovascular complications. At present, there is lack of direct evidence supporting perioperative BNP testing. Further research with randomised controlled trials is needed to confirm the benefit of BNP-guided management. Preoperative BNP testing may be considered in patients with RCRI above 0 undergoing intermediate or high-risk surgery. BNP-guided therapy is likely a beneficial addition to perioperative medicine. Its combination with β-blocker titration, RCRI and perioperative cardiovascular monitoring can be a major advance in reducing cardiac risk resulting in a dynamic, individualised optimisation process.

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Identification and guided treatment of ventricular dysfunction in general practice using blood B-type natriuretic peptide

Cited by 11 publications

References 19 publications

Improved pharmacological therapy of chronic heart failure in primary care: a randomized Study of NT‐proBNP Guided Management of Heart Failure – SIGNAL‐HF (Swedish Intervention study – Guidelines and NT‐proBNP AnaLysis in Heart Failure)

Improved pharmacological therapy of chronic heart failure in primary care: a randomized Study of NT‐proBNP Guided Management of Heart Failure – SIGNAL‐HF (Swedish Intervention study – Guidelines and NT‐proBNP AnaLysis in Heart Failure)

Trends and inequities in beta-blocker prescribing for heart failure

B-type natriuretic peptide-guided therapy for perioperative medicine?

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