Utilidad de los valores del péptido natriurético cerebral frente al control clínico habitual para la monitorización del tratamiento en pacientes con insuficiencia cardiaca

Anguita, Manuel; Esteban, Fátima; Castillo, Juan Carlos; Mazuelos, Francisco; López‐Granados, Amador; Arizón, José M.; Lezo, José Suárez de

doi:10.1016/j.medcli.2009.11.048

Cited by 25 publications

(45 citation statements)

References 15 publications

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“…Of the 13 studies included in the meta-analysis, eight were conducted in Europe (none in the UK), [53][54][55]59,[61][62][63]65 two were conducted in New Zealand, 58,64 two were conducted in North America 52,66 and one was conducted in Israel. 56 Only one RCT 63 [Swedish Intervention study -Guidelines and NT-proBNP AnaLysis in Heart Failure (SIGNAL-HF)] was conducted in primary care; 12 were conducted in hospital HF clinics, with most of these recruiting patients during or straight after hospitalisation for HF.…”

Section: Systematic Review and Meta-analysismentioning

confidence: 99%

“…Eleven RCTs used a BNP-lowering strategy [52][53][54]58,59,[61][62][63][64][65][66] and two used a BNP-monitoring strategy. 55,56 Of the 11 RCTs that used a BNP-lowering strategy, eight set a single target (BNP 100-300 pg/ml; NT-proBNP 400-2200 pg/ml), 53,54,58,59,61,[64][65][66] two of which stratified by age (< 75 years and ≥ 75 years), 54,59 and three set an individual BNP target (BNP level at discharge, reduction of 50% from baseline).…”

Section: Study Characteristicsmentioning

confidence: 99%

“…55,56 Of the 11 RCTs that used a BNP-lowering strategy, eight set a single target (BNP 100-300 pg/ml; NT-proBNP 400-2200 pg/ml), 53,54,58,59,61,[64][65][66] two of which stratified by age (< 75 years and ≥ 75 years), 54,59 and three set an individual BNP target (BNP level at discharge, reduction of 50% from baseline). 52,62,63 Treatment algorithms in the BNP group differed slightly between studies but all were based on stepwise titration of therapy according to clinical guidelines.…”

Section: Study Characteristicsmentioning

confidence: 99%

“…also provided SBP but had many missing data); cause of HF (ischaemic/non-ischaemic, there were only two RCTs with data, STARBRITE 52 and NorthStar; 55 Anguita et al 53 also provided cause of HF data but correspondence suggested that some of these data were not accurate). Figure 1 shows the flow of studies through the review process.…”

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Effectiveness and cost-effectiveness of serum B-type natriuretic peptide testing and monitoring in patients with heart failure in primary and secondary care: an evidence synthesis, cohort study and cost-effectiveness model

Pufulete

Maishman

Dabner

et al. 2017

Health Technol Assess

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BackgroundHeart failure (HF) affects around 500,000 people in the UK. HF medications are frequently underprescribed and B-type natriuretic peptide (BNP)-guided therapy may help to optimise treatment.ObjectiveTo evaluate the clinical effectiveness and cost-effectiveness of BNP-guided therapy compared with symptom-guided therapy in HF patients.DesignSystematic review, cohort study and cost-effectiveness model.SettingA literature review and usual care in the NHS.Participants(a) HF patients in randomised controlled trials (RCTs) of BNP-guided therapy; and (b) patients having usual care for HF in the NHS.InterventionsSystematic review: BNP-guided therapy or symptom-guided therapy in primary or secondary care.Cohort study: BNP monitored (≥ 6 months’ follow-upandthree or more BNP testsandtwo or more tests per year), BNP tested (≥ 1 tests but not BNP monitored) or never tested.Cost-effectiveness model: BNP-guided therapy in specialist clinics.Main outcome measuresMortality, hospital admission (all cause and HF related) and adverse events; and quality-adjusted life-years (QALYs) for the cost-effectiveness model.Data sourcesSystematic review: Individual participant or aggregate data from eligible RCTs.Cohort study: The Clinical Practice Research Datalink, Hospital Episode Statistics and National Heart Failure Audit (NHFA).Review methodsA systematic literature search (five databases, trial registries, grey literature and reference lists of publications) for published and unpublished RCTs.ResultsFive RCTs contributed individual participant data (IPD) and eight RCTs contributed aggregate data (1536 participants were randomised to BNP-guided therapy and 1538 participants were randomised to symptom-guided therapy). For all-cause mortality, the hazard ratio (HR) for BNP-guided therapy was 0.87 [95% confidence interval (CI) 0.73 to 1.04]. Patients who were aged < 75 years or who had heart failure with a reduced ejection fraction (HFrEF) received the most benefit [interactions (p = 0.03): < 75 years vs. ≥ 75 years: HR 0.70 (95% CI 0.53 to 0.92) vs. 1.07 (95% CI 0.84 to 1.37); HFrEF vs. heart failure with a preserved ejection fraction (HFpEF): HR 0.83 (95% CI 0.68 to 1.01) vs. 1.33 (95% CI 0.83 to 2.11)]. In the cohort study, incident HF patients (1 April 2005–31 March 2013) were never tested (n = 13,632), BNP tested (n = 3392) or BNP monitored (n = 71). Median survival was 5 years; all-cause mortality was 141.5 out of 1000 person-years (95% CI 138.5 to 144.6 person-years). All-cause mortality and hospital admission rate were highest in the BNP-monitored group, and median survival among 130,433 NHFA patients (1 January 2007–1 March 2013) was 2.2 years. The admission rate was 1.1 patients per year (interquartile range 0.5–3.5 patients). In the cost-effectiveness model, in patients aged < 75 years with HFrEF or HFpEF, BNP-guided therapy improves median survival (7.98 vs. 6.46 years) with a small QALY gain (5.68 vs. 5.02) but higher lifetime costs (£64,777 vs. £58,139). BNP-guided therapy is cost-effective at a threshold of £20,000 per QALY.LimitationsThe limitations of the trial were a lack of IPD for most RCTs and heterogeneous interventions; the inability to identify BNP monitoring confidently, to determine medication doses or to distinguish between HFrEF and HFpEF; the use of a simplified two-state Markov model; a focus on health service costs and a paucity of data on HFpEF patients aged < 75 years and HFrEF patients aged ≥ 75 years.ConclusionsThe efficacy of BNP-guided therapy in specialist HF clinics is uncertain. If efficacious, it would be cost-effective for patients aged < 75 years with HFrEF. The evidence reviewed may not apply in the UK because care is delivered differently.Future workIdentify an optimal BNP-monitoring strategy and how to optimise HF management in accordance with guidelines; update the IPD meta-analysis to include the Guiding Evidence Based Therapy Using Biomarker Intensified Treatment (GUIDE-IT) RCT; collect routine long-term outcome data for completed and ongoing RCTs.Trial registrationCurrent Controlled Trials ISRCTN37248047 and PROSPERO CRD42013005335.FundingThis project was funded by the NIHR Health Technology Assessment programme and will be published in full inHealth Technology Assessment; Vol. 21, No. 40. See the NIHR Journals Library website for further project information. The British Heart Foundation paid for Chris A Rogers’ and Maria Pufulete’s time contributing to the study. Syed Mohiuddin’s time is supported by the NIHR Collaboration for Leadership in Applied Health Research and Care West at University Hospitals Bristol NHS Foundation Trust. Rachel Maishman contributed to the study when she was in receipt of a NIHR Methodology Research Fellowship.

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Section: Systematic Review and Meta-analysismentioning

confidence: 99%

Section: Study Characteristicsmentioning

confidence: 99%

Section: Study Characteristicsmentioning

confidence: 99%

mentioning

confidence: 99%

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Effectiveness and cost-effectiveness of serum B-type natriuretic peptide testing and monitoring in patients with heart failure in primary and secondary care: an evidence synthesis, cohort study and cost-effectiveness model

Pufulete

Maishman

Dabner

et al. 2017

Health Technol Assess

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“…38 Following a small pilot study published in 2000, 39 a series of randomized trials, all of them relatively small and most single-blinded, examined the use of NP-guided therapy in patients with HF. They included the STARS-BNP, 40 TIME-CHF, 41 SIGNAL HF, 42 and PRIMA trials 43 ; the Vienna study 44 ; the BATTLESCARRED, 45 PROTECT, 46 UP-STEP, 47 and STARBRITE 48 studies; and a small (n 5 60) trial by Anguita et al 49 Primary results from these studies were published from 2007 to 2011. With the exceptions of SIGNAL HF and Anguita et al, the study comparisons showed an advantage for BNP-guided therapy over the comparator arm.…”

Section: Natriuretic Peptidesmentioning

confidence: 99%

Biomarker-Guided Therapies in Heart Failure: A Forum for Unified Strategies

Fiuzat¹,

O’Connor²,

Gueyffier³

et al. 2013

Journal of Cardiac Failure

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The complexity of standard medical treatment for heart failure is growing, and such therapy typically involves 5 or more different medications. Given these pressures, there is increasing interest in harnessing cardiovascular biomarkers for clinical application to more effectively guide diagnosis, risk stratification, and therapy. It may be possible to realize an era of personalized medicine for heart failure treatment in which therapy is optimized and costs are controlled. The direct mechanistic coupling of biologic processes and therapies achieved in cancer treatment remains elusive in heart failure. Recent clinical trials and metaanalyses of biomarkers in heart failure have produced conflicting evidence. In this article, which comprises a summary of discussions from the Global Cardiovascular Clinical Trialists Forum held in Paris, France, we offer a brief overview of the background and rationale for biomarker testing in heart failure, describe opportunities and challenges from a regulatory perspective, and summarize current positions from government agencies in the United States and European Union. (J Cardiac Fail 2013;19:592e599) Key Words: Pharmacogenetics, biologic markers, clinical trials, cardiovascular diseases.Personalized medicine is the practice of obtaining nonobvious information, such as biomarkers, from an individual patient for the purpose of guiding therapeutic decisions tailored to that patient's needs. In the field of oncology, biomarker testing is used to identify treatments for highly specific molecular targets to match effective therapies to specific populations, thereby improving tolerance to treatments with toxicity profiles that would be unacceptable in an unselected population. 1e3 The clinical utility of biomarkers in the arena of cardiology is less clear, due in part to the fact that usual practice groups together several pathways leading to heart failure (HF) as well as the corresponding selection of therapies.In addition, the heterogeneity of HF compared with a given type of cancer adds a complicating factor. Oncotype diagnostic assays use multimarker profiling to assess therapeutic options in oncology. Most of these profile somatic alterations (eg, estrogen receptor or HERG2 status in tumor cells) that are usually related to tumor cell mutations. In cardiology, however, genetic variants likely to influence therapeutic decisions are typically germline and as such only indirectly modify disease prognosis or response to therapy. Historical and biologic factors affecting the focus of research to date may also explain the relatively more thorough investigation of biomarkers in oncology. For instance, estrogen receptor status in breast cancer directly

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B-type natriuretic peptide-guided treatment for heart failure

McLellan

Heneghan

Perera

et al. 2016

Cochrane Database of Systematic Reviews

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Background Heart failure is a condition in which the heart does not pump enough blood to meet all the needs of the body. Symptoms of heart failure include breathlessness, fatigue and fluid retention. Outcomes for patients with heart failure are highly variable; however on average, these patients have a poor prognosis. Prognosis can be improved with early diagnosis and appropriate use of medical treatment, use of devices and transplantation. Patients with heart failure are high users of healthcare resources, not only due to drug and device treatments, but due to high costs of hospitalisation care. B‐type natriuretic peptide levels are already used as biomarkers for diagnosis and prognosis of heart failure, but could offer to clinicians a possible tool to guide drug treatment. This could optimise drug management in heart failure patients whilst allaying concerns over potential side effects due to drug intolerance. Objectives To assess whether treatment guided by serial BNP or NT‐proBNP (collectively referred to as NP) monitoring improves outcomes compared with treatment guided by clinical assessment alone. Search methods Searches were conducted up to 15 March 2016 in the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library; MEDLINE (OVID), Embase (OVID), the Database of Abstracts of Reviews of Effects (DARE) and the NHS Economic Evaluation Database in the Cochrane Library. Searches were also conducted in the Science Citation Index Expanded, the Conference Proceedings Citation Index on Web of Science (Thomson Reuters), World Health Organization International Clinical Trials Registry and ClinicalTrials.gov. We applied no date or language restrictions. Selection criteria We included randomised controlled trials of NP‐guided treatment of heart failure versus treatment guided by clinical assessment alone with no restriction on follow‐up. Adults treated for heart failure, in both in‐hospital and out‐of‐hospital settings, and trials reporting a clinical outcome were included. Data collection and analysis Two review authors independently selected studies for inclusion, extracted data and evaluated risk of bias. Risk ratios (RR) were calculated for dichotomous data, and pooled mean differences (MD) (with 95% confidence intervals (CI)) were calculated for continuous data. We contacted trial authors to obtain missing data. Using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, we assessed the quality of the evidence and GRADE profiler (GRADEPRO) was used to import data from Review Manager to create a 'Summary of findings' table. Main results We included 18 randomised controlled trials with 3660 participants (range of mean age: 57 to 80 years) comparing NP‐guided treatment with clinical assessment alone. The evidence for all‐cause mortality using NP‐guided treatment showed uncertainty (RR 0.87, 95% CI 0...

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Utilidad de los valores del péptido natriurético cerebral frente al control clínico habitual para la monitorización del tratamiento en pacientes con insuficiencia cardiaca

Cited by 25 publications

References 15 publications

Effectiveness and cost-effectiveness of serum B-type natriuretic peptide testing and monitoring in patients with heart failure in primary and secondary care: an evidence synthesis, cohort study and cost-effectiveness model

Effectiveness and cost-effectiveness of serum B-type natriuretic peptide testing and monitoring in patients with heart failure in primary and secondary care: an evidence synthesis, cohort study and cost-effectiveness model

Biomarker-Guided Therapies in Heart Failure: A Forum for Unified Strategies

B-type natriuretic peptide-guided treatment for heart failure

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