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Brain-Type Natriuretic Peptide and Amino-Terminal Pro-Brain-Type Natriuretic Peptide Discharge Thresholds for Acute
Casey N McQuade1, Marisa Mizus1, Joyce W Wald1
1From Perelman School of Medicine, University of Pennsylvania, and Penn Medicine Center for Evidence-based Practice, University of Pennsylvania Health System, Philadelphia, Pennsylvania.
Background:
Acute decompensated heart failure (ADHF) requiring hospitalization is associated with high postdischarge mortality and readmission rates.
Purpose:
To examine the association between achieving predischarge natriuretic peptide (NP) thresholds and mortality and readmission rates in adults hospitalized for ADHF.
Data Sources:
Multiple databases from 1947 to October 2016 (English-language studies only).
Study Selection:
Trials and observational studies that compared mortality and readmission outcomes between patients with ADHF achieving a specific predischarge NP goal and those not achieving the goal.
Data Extraction:
Two investigators independently extracted study characteristics and assessed study risk of bias. One author graded the overall strength of evidence, with review by a second author.
Data Synthesis:
One randomized trial, 3 quasi-experimental studies, and 40 observational studies were identified. The most commonly used thresholds were a brain-type NP (BNP) level of 250 pg/mL or less or an amino-terminal pro-brain-type NP (NT-proBNP) decrease of at least 30%. Achievement of absolute BNP thresholds reduced postdischarge all-cause mortality (7 of 8 studies) and the composite outcome of mortality and readmission (12 of 14 studies). Achievement of percentage-change BNP thresholds reduced the composite outcome (5 of 6 studies), and achievement of percentage-change NT-proBNP thresholds reduced all-cause and cardiovascular mortality (2 of 4 studies) and the composite outcome (9 of 9 studies). All findings were low-strength. The randomized trial, assessed as having high risk of bias, suggested that a predischarge decrease in NT-proBNP level was associated with lower risk for the composite outcome. Two quasi-experimental studies and 5 observational studies had low risk of bias. Low-risk-of-bias studies had outcome estimates similar in magnitude and direction to estimates from high-risk-of-bias studies.
Limitation:
Most studies failed to adjust for critical confounders and had inadequate definition or assessment of exposures and outcomes.
Conclusion:
Low-strength evidence suggests an association between achieving NP predischarge thresholds and reduced ADHF mortality and readmission.
Primary Funding Source:
None.
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