Natriuretic peptide-guided treatment for heart failure: a systematic review and meta-analysis

Abstract

BackgroundGUIDE-IT, the largest trial to date, published in August 2017, evaluating the effectiveness of natriuretic peptide (NP)-guided treatment of heart failure (HF), was stopped early for futility on a composite outcome. However, the reported effect sizes on individual outcomes of all-cause mortality and HF admissions are potentially clinically relevant.ObjectiveThis systematic review and meta-analysis aims to combine all available trial level evidence to determine if NP-guided treatment of HF reduces all-cause mortality and HF admissions in patients with HF.Study selectionEight databases, no language restrictions, up to November 2017 were searched for all randomised controlled trials comparing NP-guided treatment versus clinical assessment alone in adult patients with HF. No language restrictions were applied. Publications were independently double screened and extracted. Fixed-effect meta-analyses were conducted.Findings89 papers were included, reporting 19 trials (4554 participants), average ages 62–80 years. Pooled risk ratio estimates for all-cause mortality (16 trials, 4063 participants) were 0.87, 95% CI 0.77 to 0.99 and 0.80, 95% CI 0.72 to 0.89 for HF admissions (11 trials, 2822 participants). Sensitivity analyses, restricted to low risk of bias, produced similar estimates, but were no longer statistically significant.ConclusionsConsidering all the evidence to date, the pooled effects suggest that NP-guided treatment is beneficial in reducing HF admissions and all-cause mortality. However, there is still insufficient high-quality evidence to make definitive recommendations on the use of NP-guided treatment in clinical practice.Trial registration numberSystematic Review Cochrane Database Number: CD008966.

Congestion in heart failure: a circulating biomarker‐based perspective. A review from the Biomarkers Working Group of the Heart Failure Association, European Society of Cardiology

“…The evidence endorsing the utility of NPs for guiding therapy is mixed. The largest trial and the more recent meta‐analysis showed no prognostic benefit compared to usual care 42,43 . The GUIDE‐IT included 894 patients with stable LV ejection fraction ≤40% and elevated NT‐proBNP in the previous month 43 .…”

The Effect in Renal Function and Vascular Decongestion in Type 1 Cardiorenal Syndrome Treated with Two Strategies of Diuretics, a Pilot Randomized Trial

“…Acute decreases in renal function after ADHF undergoing aggressive decongestion with high-dose loop diuretics does not necessarily reflect structural injury to the kidneys [22]. Third, this "lack of effectiveness" to renal recovery was accompanied by a reduction in BNP (− 1365 ± 1574), and even during treatment it was possible to decrease BNP > 30% in 36% of cases, an event that can be interpreted as effective decongestion, that is significantly associated with greater survival in the median long term [23], and guiding the treatment of these patients with natriuretic peptides has been proven to decrease their probability of hospitalizations by 20% and their probability of dying by 13% [24].…”

Atualização de Tópicos Emergentes da Diretriz Brasileira de Insuficiência Cardíaca – 2021

“…Além disso, uma metanálise recente, feita com 4.554 pacientes e incorporando os pacientes do estudo GUIDE-IT, mostrou redução de hospitalizações e mortalidade por todas as causas com o tratamento guiado pelos peptídeos natriuréticos. 111 IC: insuficiência cardíaca; NT: proBNP-fração N-terminal do peptídeo natriurético atrial do tipo B. A incorporação do sequenciamento de última geração têm aumentado a sensibilidade dos testes genéticos, possibilitando o diagnóstico precoce com perspectiva de intervenção.…”