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Published on: May 19, 2020
Impact of Natriuretic Peptide and Prior Hospitalization in Patients With Severe Mitral Regurgitation: COAPT Trial
Sachin S Goel1, Ashrith Guha1, JoAnn Lindenfeld2
1Houston Methodist Hospital, TX (S.S.G., A.G., S.H.L., M.J.R., N.S.K.).
Insights
Elevated natriuretic peptide levels and prior heart failure hospitalizations increase risks for patients undergoing mitral transcatheter edge-to-edge repair. However, this repair procedure consistently reduces death and heart failure hospitalizations across all severity levels.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Heart Failure Management
Background:
- The clinical impact of elevated natriuretic peptide levels and prior heart failure hospitalizations (HFH) on outcomes following transcatheter edge-to-edge repair (TEER) for severe secondary mitral regurgitation remains unclear.
- This study investigates the influence of B-type natriuretic peptide (BNP) or N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels and previous HFH on patient outcomes in the context of TEER.
Purpose of the Study:
- To evaluate the prognostic significance of elevated baseline natriuretic peptide levels and prior HFH in patients with severe secondary mitral regurgitation undergoing TEER.
- To assess the impact of these factors on outcomes, specifically the composite endpoint of death or HFH at 2 years.
Main Methods:
- Analysis of data from the COAPT trial, a randomized controlled trial comparing TEER with the MitraClip device versus guideline-directed medical therapy (GDMT) alone.
- Patients were stratified into mild, moderate, and severe heart failure (HF) groups based on prior HFH and baseline BNP/NT-proBNP levels relative to the median.
- Primary endpoint was the 2-year rate of death or HFH.
Main Results:
- In the GDMT alone arm, 2-year rates of death or HFH increased with HF severity, ranging from 56.4% in mild HF to 84.1% in severe HF (Ptrend=0.001).
- Patients with moderate HF and a prior HFH had significantly higher rates (48.7%) compared to those with only elevated BNP/NT-proBNP (73.4%) (P=0.003).
- TEER demonstrated a consistent reduction in death/HFH compared to GDMT alone across all HF severity groups (Pinteraction=0.50).
Conclusions:
- Elevated baseline BNP/NT-proBNP and prior HFH are associated with increased 2-year death/HFH rates in patients with severe secondary mitral regurgitation.
- Mitral TEER provides consistent benefits in reducing mortality and HFH, irrespective of the baseline HF severity or the presence of elevated natriuretic peptides and prior hospitalizations.
Background:
The clinical significance of elevated baseline natriuretic peptide level and prior heart failure hospitalization (HFH) within the prior year in mitral transcatheter edge-to-edge repair outcomes is unclear. This analysis examined the impact of BNP (B-type natriuretic peptide) or NT-proBNP (N-terminal pro-B-type natriuretic peptide) and prior HFH on outcomes in patients with severe secondary mitral regurgitation.
Methods:
The COAPT trial (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation) was a randomized controlled trial of subjects assigned to mitral valve transcatheter edge-to-edge repair with the MitraClip device versus guideline-directed medical therapy alone. COAPT patients were grouped by BNP/NT-proBNP levels and prior HFH within 1 year: (1) Mild heart failure (HF): no prior HFH with BNP/NT-proBNP
Results:
Of 572 patients, mild, moderate, and severe HF were present in 125 (21.9%), 288 (50.3%), and 159 (27.8%) patients, respectively. With guideline-directed medical therapy alone, the 2-year rates of death or HFH in mild, moderate, and severe HF were 56.4%, 60.5%, and 84.1%, respectively (Ptrend=0.001). These rates were 48.7% and 73.4% among patients with moderate HF and a prior HFH only versus elevated BNP/NT-proBNP≥median only (P=0.003). Mitral transcatheter edge-to-edge repair reduced death/HFH compared with guideline-directed medical therapy alone regardless of HF severity (Pinteraction=0.50).
Conclusions:
In patients with HF with severe secondary mitral regurgitation enrolled in the COAPT trial, 2-year rates of death/HFH were increased with an elevated baseline BNP/NT-proBNP≥median, and more so if HFH within 1 year prior had occurred. Treatment with mitral transcatheter edge-to-edge repair reduced all-cause mortality and HFH consistently in mild, moderate, and severe HF.
Registration:
URL: https://www.clinicaltrials.gov; Unique identifier: NCT01626079.
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