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Natriuretic peptide-guided treatment for heart failure: a systematic review and meta-analysis
Julie McLellan1, Clare R Bankhead1, Jason L Oke1
1Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
Insights
Natriuretic peptide (NP)-guided treatment may reduce heart failure (HF) admissions and all-cause mortality. However, current evidence is insufficient for definitive clinical practice recommendations.
Area of Science:
- Cardiology
- Clinical Trials
- Evidence-Based Medicine
Background:
- The largest trial on natriuretic peptide (NP)-guided heart failure (HF) treatment, GUIDE-IT, was stopped early for futility.
- However, potential clinical benefits regarding mortality and HF admissions warrant further investigation.
Purpose of the Study:
- To systematically review and meta-analyze all available trial-level evidence on NP-guided HF treatment.
- To determine the efficacy of NP-guided treatment in reducing all-cause mortality and HF admissions.
Main Methods:
- Systematic review and meta-analysis of randomized controlled trials comparing NP-guided treatment versus clinical assessment.
- Searched eight databases with no language restrictions up to November 2017.
- Included 19 trials with 4554 participants.
Main Results:
- Pooled analysis of 16 trials (4063 participants) showed a risk ratio of 0.87 (95% CI 0.77 to 0.99) for all-cause mortality.
- Pooled analysis of 11 trials (2822 participants) showed a risk ratio of 0.80 (95% CI 0.72 to 0.89) for HF admissions.
- Sensitivity analyses using low risk of bias trials yielded similar estimates, but they were not statistically significant.
Conclusions:
- Pooled effects suggest NP-guided treatment benefits patients by reducing HF admissions and all-cause mortality.
- However, high-quality evidence remains insufficient to guide clinical practice.
- Further research is needed to confirm these findings and establish definitive recommendations.
Background:
GUIDE-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.
Objective:
This 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 Selection:
Eight 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.
Findings:
89 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.
Conclusions:
Considering 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 Number:
Systematic Review Cochrane Database Number: CD008966.
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