Brain-type natriuretic peptide and amino-terminal pro-brain-type natriuretic peptide discharge thresholds for acute decompensated heart failure: A systematic review

Casey N. McQuade, Marisa Mizus, Joyce W. Wald, Lee Goldberg, Mariell Jessup, Craig A. Umscheid

Research output: Contribution to journalReview articlepeer-review

Abstract

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.

Original languageEnglish (US)
Pages (from-to)180-190
Number of pages11
JournalAnnals of internal medicine
Volume166
Issue number3
DOIs
StatePublished - Feb 7 2017
Externally publishedYes

ASJC Scopus subject areas

  • Internal Medicine

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