Echo- and B-Type Natriuretic Peptide-Guided Follow-Up versus Symptom-Guided Follow-Up: Comparison of the Outcome in Ambulatory Heart Failure Patients

Abstract

Recent European Society of Cardiology and American Heart Association/American College of Cardiology Guidelines did not recommend biomarker-guided therapy in the management of heart failure (HF) patients. Combination of echo- and B-type natriuretic peptide (BNP) may be an alternative approach in guiding ambulatory HF management. Our aim was to determine whether a therapy guided by echo markers of left ventricular filling pressure (LVFP), lung ultrasound (LUS) assessment of B-lines, and BNP improves outcomes of HF patients. Consecutive outpatients with LV ejection fraction (EF) ≤ 50% have been prospectively enrolled. In Group I (n=224), follow-up was guided by echo and BNP with the goal of achieving E-wave deceleration time (EDT) ≥ 150 ms, tissue Doppler index E/e' < 13, B-line numbers < 15, and BNP ≤ 125 pg/ml or decrease >30%; in Group II (n=293), follow-up was clinically guided, while the remaining 277 patients (Group III) did not receive any dedicated follow-up. At 60 months, survival was 88% in Group I compared to 75% in Group II and 54% in Group III (χ ² 53.5; p < 0.0001). Survival curves exhibited statistically significant differences using Mantel-Cox analysis. The number needed to treat to spare one death was 7.9 (Group I versus Group II) and 3.8 (Group I versus Group III). At multivariate Cox regression analyses, major predictors of all-cause mortality were follow-up E/e' (HR: 1.05; p=0.0038) and BNP >125 pg/ml or decrease ≤30% (HR: 4.90; p=0.0054), while BNP > 125 pg/ml or decrease ≤30% and B-line numbers ≥15 were associated with the combined end point of death and HF hospitalization. Evidence-based HF treatment guided by serum biomarkers and ultrasound with the goal of reducing elevated BNP and LVFP, and resolving pulmonary congestion was associated with better clinical outcomes and can be valuable in guiding ambulatory HF management.

Figure 1

Predefined titration protocol. ACEI: angiotensin-converting enzyme inhibitors; ARB: angiotensin receptor blockers; ARNI: angiotensin receptor neprilysin inhibitors; BB: beta-blockers; BNP: B-type natriuretic peptide; EDT: E-wave deceleration time; E/e′: ratio of E/averaged myocardial early velocity; MRI: mineralocorticoid receptors inhibitors; LUS: lung ultrasound.

Figure 2

Frequencies of patients with an E-wave deceleration time (EDT) < 150 ms, a ratio of E/averaged myocardial early velocity (averaged E/e′) ≥ 13, and presence of ≥15 B-lines at lung ultrasound. Comparison between baseline (dark gray bar) and follow-up (light gray bar).

Figure 3

(a) Survival free from all-cause mortality in patients of the echo- and BNP-guided follow-up, in patients of the clinically driven follow-up, and in those who received no specific follow-up care (X² 53.5; p < 0.0001). (b) Survival curves for the combined end point of death or hospitalization for worsening heart failure in echo- and BNP-guided and symptom-guided groups and in patients who received no specific follow-up care (X² 72.4; p < 0.0001). When compared to patients of the symptom-guided group and those who did not receive any organized follow-up care, life was estimated to be prolonged by an average of 2.5 years and 4 years, respectively, by the echo- and BNP-guided strategy. Similar results were attained with the event-free life gain.