Natriuretic peptide-guided therapy in chronic heart failure: a meta-analysis of 2,686 patients in 12 randomized trials

Abstract

Background: The role of cardiac natriuretic peptides in the management of patients with chronic heart failure (HF) remains uncertain. The purpose of this study was to evaluate whether natriuretic peptide-guided therapy, compared to clinically-guided therapy, improves mortality and hospitalization rate in patients with chronic HF.

Methodology/principal findings: MEDLINE, Cochrane, ISI Web of Science and SCOPUS databases were searched for articles reporting natriuretic peptide-guided therapy in HF until August 2012. All randomized trials reporting clinical end-points (all-cause mortality and/or HF-related hospitalization and/or all-cause hospitalization) were included. Meta-analysis was performed to assess the influence of treatment on outcomes. Sensitivity analysis was performed to test the influence of potential effect modifiers and of each trial included in meta-analysis on results. Twelve trials enrolling 2,686 participants were included. Natriuretic peptide-guided therapy (either B-type natriuretic peptide [BNP]- or N-terminal pro-B-type natriuretic peptide [NT-proBNP]-guided therapy) significantly reduced all-cause mortality (Odds Ratio [OR]:0.738; 95% Confidence Interval [CI]:0.596 to 0.913; p = 0.005) and HF-related hospitalization (OR:0.554; CI:0.399 to 0.769; p = 0.000), but not all-cause hospitalization (OR:0.803; CI:0.629 to 1.024; p = 0.077). When separately assessed, NT-proBNP-guided therapy significantly reduced all-cause mortality (OR:0.717; CI:0.563 to 0.914; p = 0.007) and HF-related hospitalization (OR:0.531; CI:0.347 to 0.811; p = 0.003), but not all-cause hospitalization (OR:0.779; CI:0.414 to 1.465; p = 0.438), whereas BNP-guided therapy did not significantly reduce all-cause mortality (OR:0.814; CI:0.518 to 1.279; p = 0.371), HF-related hospitalization (OR:0.599; CI:0.303 to 1.187; p = 0.142) or all-cause hospitalization (OR:0.726; CI:0.509 to 1.035; p = 0.077). [corrected].

Conclusions/significance: Use of cardiac peptides to guide pharmacologic therapy significantly reduces mortality and HF related hospitalization in patients with chronic HF. In particular, NT-proBNP-guided therapy reduced all-cause mortality and HF-related hospitalization but not all-cause hospitalization, whereas BNP-guided therapy did not significantly reduce both mortality and morbidity.

Figure 1. Flow chart showing the progress through the stages of the meta-analysis.

Figure 2. Odds ratios of all-cause mortality.

Solid squares represent odds ratios in trials and have a size proportional to the number of events. The 95% confidence intervals for individual trials are denoted by lines and those for the pooled odd ratios by empty diamonds.

Figure 3. Odds ratios of heart failure-related hospitalization.

Solid squares represent odds ratios in trials and have a size proportional to the number of events. The 95% confidence intervals for individual trials are denoted by lines and those for the pooled odd ratios by empty diamonds.

Figure 4. Odds ratios of all-cause hospitalization.

Solid squares represent odds ratios in trials and have a size proportional to the number of events. The 95% confidence intervals for individual trials are denoted by lines and those for the pooled odd ratios by empty diamonds.

Figure 5. One study removed analysis for all-cause mortality.

Rows represent the results of meta-analysis of all studies except the omitted study named in that row.

Figure 6. One study removed analysis for heart failure-related hospitalization.

Rows represent the results of meta-analysis of all studies except the omitted study named in that row.

Figure 7. One study removed analysis for all-cause hospitalization.

Rows represent the results of meta-analysis of all studies except the omitted study named in that row.