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Presenter report:
Brunner-La Rocca, Hans Peter (Switzerland)
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Background: It is uncertain whether intensified, NT-BNP-guided therapy of heart failure (HF) improves outcome compared to standard, symptom-guided therapy, and whether there is a difference in the response in patients ≥ versus <75 years of age.
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Methods: Therefore, 499 patients with systolic HF (ejection fraction £45%) were randomised to an NT-BNP-guided or a symptom-guided strategy and stratified into patients aged ≥75 versus 60-74years. Included were patients with dyspnea NYHA ≥II, HF hospitalizations within one year and NT-BNP levels >400pg/ml (60-74years) or 800pg/ml (≥75years). Therapy was uptitrated according to guidelines aiming to reduce symptoms to NYHA£II or additionally NT-BNP-levels below levels mentioned above. The primary endpoint was survival free of all-cause hospitalisations up to 18 months and quality of life. Secondary endpoints were survival and HF hospitalization-free survival.
Results: Compared to standard therapy, intensified treatment did not improve primary endpoint (hazard ratio (HR)=0.92, p=0.46), but did improve the more disease-specific endpoint of survival free of HF hospitalisations (HR=0.66, p=0.008). Intensified therapy reduced total mortality (HR=0.38, p=0.01) and improved survival free of HF hospitalisations (HR=0.41, p=0.002) in younger patients, but not in those ≥75years. In addition, quality of life improved less by intensified versus standard therapy in older patients despite similar reductions in symptoms and BNP-levels.
Conclusions: Intensified HF therapy did not improve overall outcome compared to standard treatment. However, it improved survival free of HF hospitalizations overall and it reduced mortality in patients <75 years of age, without similar benefits in older patients. Specific HF trials in very elderly patients are warranted.
Discussant: Dickstein, Kenneth (Norway) 