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?


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.


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.


The authors concluded that assessment of baseline and follow-up BNP provides important prognostic implications in mildly symptomatic HF patients who receive CRT.


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.

Clinical Topics: Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Implantable Devices, SCD/Ventricular Arrhythmias, Acute Heart Failure, Heart Failure and Cardiac Biomarkers

Keywords: Heart Diseases, Defibrillators, Cardiac Pacing, Artificial, Heart Failure, Transcription Factors, Defibrillators, Implantable, Cardiac Resynchronization Therapy, Natriuretic Peptide, Brain

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