B-type natriuretic peptide-guided therapy for heart failure (HF): a systematic review and meta-analysis of individual participant data (IPD) and aggregate data.

Autor: Pufulete M; Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Level 7, Bristol Royal Infirmary, Queen's Building, Bristol, BS2 8HW, UK. maria.pufulete@bristol.ac.uk., Maishman R; Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Level 7, Bristol Royal Infirmary, Queen's Building, Bristol, BS2 8HW, UK., Dabner L; Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Level 7, Bristol Royal Infirmary, Queen's Building, Bristol, BS2 8HW, UK., Higgins JPT; School of Social and Community Medicine, University of Bristol, Bristol, UK., Rogers CA; Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Level 7, Bristol Royal Infirmary, Queen's Building, Bristol, BS2 8HW, UK., Dayer M; Department of Cardiology, Taunton and Somerset NHS Foundation Trust, Taunton, UK., MacLeod J; School of Social and Community Medicine, University of Bristol, Bristol, UK., Purdy S; School of Social and Community Medicine, University of Bristol, Bristol, UK., Hollingworth W; School of Social and Community Medicine, University of Bristol, Bristol, UK., Schou M; Herlev and Gentofte University Hospital, Herlev, DK-2730, Copenhagen, Denmark., Anguita-Sanchez M; Agencia de Investigación de la Sociedad Española de Cardiología, Madrid, Spain., Karlström P; Division of Cardiology, Department of Medicine, County Hospital Ryhov, Jönköping, Sweden., Shochat MK; Heart Institute, Hillel Yaffe Medical Center, Hadera, Israel., McDonagh T; Cardiovascular Division, King's College Hospital, King's College London, Denmark Hill, London, SE5 9RS, UK., Nightingale AK; Department of Cardiology, Bristol Heart Institute, Bristol Royal Infirmary, Bristol, BS2 8HW, UK., Reeves BC; Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Level 7, Bristol Royal Infirmary, Queen's Building, Bristol, BS2 8HW, UK.
Jazyk: angličtina
Zdroj: Systematic reviews [Syst Rev] 2018 Jul 31; Vol. 7 (1), pp. 112. Date of Electronic Publication: 2018 Jul 31.
DOI: 10.1186/s13643-018-0776-8
Abstrakt: Background: We estimated the effectiveness of serial B-type natriuretic peptide (BNP) blood testing to guide up-titration of medication compared with symptom-guided up-titration of medication in patients with heart failure (HF).
Methods: Systematic review and meta-analysis of randomised controlled trials (RCTs). We searched: MEDLINE (Ovid) 1950 to 9/06/2016; Embase (Ovid), 1980 to 2016 week 23; the Cochrane Library; ISI Web of Science (Citations Index and Conference Proceedings). The primary outcome was all-cause mortality; secondary outcomes were death related to HF, cardiovascular death, all-cause hospital admission, hospital admission for HF, adverse events, and quality of life. IPD were sought from all RCTs identified. Random-effects meta-analyses (two-stage) were used to estimate hazard ratios (HR) and confidence intervals (CIs) across RCTs, including HR estimates from published reports of studies that did not provide IPD. We estimated treatment-by-covariate interactions for age, gender, New York Heart Association (NYHA) class, HF type; diabetes status and baseline BNP subgroups. Dichotomous outcomes were analysed using random-effects odds ratio (OR) with 95% CI.
Results: We identified 14 eligible RCTs, five providing IPD. BNP-guided therapy reduced the hazard of hospital admission for HF by 19% (13 RCTs, HR 0.81, 95% CI 0.68 to 0.98) but not all-cause mortality (13 RCTs; HR 0.87, 95% CI 0.75 to 1.01) or cardiovascular mortality (5 RCTs; OR 0.88, 95% CI 0.67 to 1.16). For all-cause mortality, there was a significant interaction between treatment strategy and age (p = 0.034, 11 RCTs; HR 0.70, 95% CI 0.53-0.92, patients < 75 years old and HR 1.07, 95% CI 0.84-1.37, patients ≥ 75 years old); ejection fraction (p = 0.026, 11 RCTs; HR 0.84, 95% CI 0.71-0.99, patients with heart failure with reduced ejection fraction (HFrEF); and HR 1.33, 95% CI 0.83-2.11, patients with heart failure with preserved ejection fraction (HFpEF)). Adverse events were significantly more frequent with BNP-guided therapy vs. symptom-guided therapy (5 RCTs; OR 1.29, 95% CI 1.04 to 1.60).
Conclusion: BNP-guided therapy did not reduce mortality but reduced HF hospitalisation. The overall quality of the evidence varied from low to very low. The relevance of these findings to unselected patients, particularly those managed by community generalists, are unclear.
Systematic Review Registration: PROSPERO CRD42013005335.
Databáze: MEDLINE
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