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Is natriuretic peptide lowering strategy superior to symptomatically based management of chronic heart failure with reduced ejection fraction?

      Despite significant furtherance in the medical management of heart failure (HF), readmission and mortality following HF hospitalization are significantly high. Traditionally, optimization of medical therapy, which includes angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, diuretics, and aldosterone antagonist is mainly guided by symptomatology and patient tolerance. Left ventricular wall stretch provokes secretion of plasma brain natriuretic peptide (BNP) and N-terminal pro BNP (NT-pro BNP), which are proposed as markers to guide and optimize medical therapy. Several studies have reported natriuretic peptide guided therapy to be superior in reducing HF readmission events and mortality as contrasted with clinical symptoms guided therapy alone [
      • Troughton RW
      • Frampton CM
      • Yandle TG
      • Espine EA
      • Nicholls MG
      • Richards AM
      Treatment of heart failure guided by plasma aminoterminal brain natriuretic peptide (N-BNP) concentrations.
      ,
      • Jourdain P
      • Jondeau G
      • Funck F
      • Gueffet P
      • Le Helloco A
      • Donal E
      • et al.
      Plasma brain natriuretic peptide-guided therapy to improve outcome in heart failure: the STARS-BNP multicenter study.
      ]. However, the results are inconsistent. Additionally, the 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure documents the following statement – “Because of the absence of clear and consistent evidence for improvement in mortality and cardiovascular outcomes, there are insufficient data to inform specific guideline recommendations related to natriuretic peptide–guided therapy or serial measurements of BNP or NT-proBNP levels for the purpose of reducing hospitalization or deaths in the present document” . Former meta-analyses pooled clinically heterogeneous studies of patients with acute/chronic HF and heart failure with reduced ejection fraction (HFrEF)/ heart failure with preserved ejection fraction (HFpEF). Hence, we performed a meta-analysis including all the randomized control trials (RCTs) comparing BNP lowering therapy to standard clinical symptoms guided therapy among patients with chronic HFrEF. The usefulness of BNP lowering strategy for guiding treatment in HFrEF will thus be inferred.
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