Can NT-proBNP guided therapy during hospital admission for acutely decompensated heart failure reduce mortality and readmissions?

Guiding therapy of heart failure (HF) by an objective measure like NT-proBNP has received intense attention. The gain that is made by this form of guidance is modest when applied to chronic heart failure (CHF) patients. Recent post discharge data from our own group does show that NT-proBNP guidance can detect important short-term changes. Studies have also shown that NT-proBNP discharge value and a >30% NT-proBNP reduction during admission are statistically significant predictors of readmissions and mortality. These data suggest a role for such NT-proBNP guidance, rather in an acute than in a chronic setting. Acute admission for HF occurs frequent: in 2004, there were almost 25,000 hospital admissions in the Netherlands. Particularly worrisome is the high percentage of readmissions which reaches 30 to 60% within 6 months, importantly increasing the economic burden of this disease. In short, in-hospital care for acutely decompensated heart failure may be improved by NT-proBNP guidance to reduce the number of readmissions.



The primary objective of the present multicenter randomized controlled trial is to demonstrate that NT-proBNP guidance during in-hospital treatment for acutely decompensated heart failure (to strive for >30% reduction) reduces readmissions and mortality and increases the number of days alive out of hospital in the first 180 days compared to therapy guided by standard clinical judgment. Morbidity and mortality is measured in terms of days alive outside the hospital within the follow-up period of 180 days.

NT-proBNP guidance during in-hospital treatment of acutely decompensated heart failure (to strive for >30% reduction) reduces readmissions and mortality and increases the number of days alive out of hospital in the first 180 days.

Endpoint assessment (readmission or death) will take place at 4 timepoints after discharge: 1 week, 1 month, 3 months and 6 months after discharge.

1. NT-proBNP guided therapy;

2. Conventional therapy.



When clinical stability is achieved, the patient is randomized in either the NT-proBNP-titrated group or the conventional therapy group. In the NT-proBNP-titrated group a NT-proBNP reduction of > 30% before discharge is pursued. When patients do not reach the >30% NT-proBNP reduction, they follow a predefined algorithm before discharge to improve the number of patients discharged with >30% reduction in NT-proBNP levels. Hence, duration of admission can be prolonged with a maximum of 2-4 days. The NT-proBNP levels of patients in the conventional treatment group will be measured but not revealed to patients, physicians or nurses. Conventional treatment encompasses the recommended therapy depicted in the current guidelines for acute heartfailure.