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Brain Natriuretic Peptide and Cardiac Resynchronization Therapy in Patients With Mildly Symptomatic Heart Failure
Study Questions:
What is the prognostic utility of B-type natriuretic peptide (BNP) assessment in patients with mild heart failure (HF) symptoms who are treated with cardiac resynchronization therapy?
Methods:
The effect of elevated baseline and 1-year BNP levels (dichotomized at the upper tertile BNP of 120 pg/ml) on the risk of HF or death was assessed among the cohort of 1,197 patients with baseline BNP data enrolled in the MADIT-CRT trial. The effect of BNP change at 1 year following cardiac resynchronization therapy-defibrillator (CRT-D) implantation on subsequent outcome was assessed by evaluating response as a categorical variable dependent on the 120 pg/ml cutoff (i.e., low baseline and low 1-year, high baseline/high 1-year, low baseline/high 1-year, high baseline/low 1-year) in the multivariate models.
Results:
Elevated baseline BNP was associated with a significant 68% (p = 0.007) and 58% (p = 0.02) increase in the risk of HF or death among MADIT-CRT patients allocated to CRT-D and implantable cardioverter-defibrillator (ICD)-only therapy, respectively. At 1 year of follow up, patients allocated to CRT-D displayed significantly greater reductions in BNP (26% reduction) levels compared with ICD-only patients (8% increase; p = 0.005). CRT-D patients in whom 1-year BNP levels were reduced or remained low experienced a significantly lower risk of subsequent HF or death as compared with patients in whom BNP levels were high at 1 year. Similarly, the echocardiographic response to CRT-D was highest among those who maintained low BNP levels or in whom BNP at 1 year was reduced.
Conclusions:
The authors concluded that assessment of baseline and follow-up BNP provides important prognostic implications in mildly symptomatic HF patients who receive CRT.
Perspective:
This study reported that elevated BNP at the time of device implant is prognostic of subsequent HF or death independent of the type of device received, and that CRT-D is associated with significant reductions in BNP levels during follow-up, whereas a similar pattern is not observed among patients who are not treated with the device. Furthermore, the pattern of BNP change and the absolute BNP value at 1 year following CRT-D implantation are related to the echocardiographic response to the device and the risk of subsequent HF or death. These findings suggest that BNP monitoring may be useful both pre- and post- CRT-D implant, but needs to be validated in a prospective study. In the setting of elevated baseline or follow-up BNP, additional device optimization, intensification of medical therapy, or referral to an advanced HF center may be appropriate.
Keywords: Heart Diseases, Defibrillators, Cardiac Pacing, Artificial, Heart Failure, Transcription Factors, Defibrillators, Implantable, Cardiac Resynchronization Therapy, Natriuretic Peptide, Brain
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