N-Terminal Pro–B-Type Natriuretic Peptide-Guided Treatment for Chronic Heart Failure

Results From the BATTLESCARRED (NT-proBNP–Assisted Treatment To Lessen Serial Cardiac Readmissions and Death) Trial

John G. Lainchbury, MD, Richard W. Troughton, MD, PhD, Kim M. Strangman, RN, Christopher M. Frampton, PhD, Anna Pilbrow, PhD, Timothy G. Yandle, PhD, Amjad K. Hamid, MBChB, M. Gary Nicholls, MD and A. Mark Richards, MD, PhD^_*

Department of Medicine, Christchurch Cardioendocrine Research Group, University of Otago, Christchurch, New Zealand

Manuscript received November 26, 2008; revised manuscript received February 19, 2009, accepted February 24, 2009.

^_* Reprint requests and correspondence: Dr. A. Mark Richards, The Christchurch Cardioendocrine Research Group, Department of Medicine, University of Otago, P.O. Box 4345, Christchurch 8140, New Zealand (Email: mark.richards@cdhb.govt.nz).

Objectives: The purpose of this study was to compare the effects of N-terminal pro–B-type natriuretic peptide (NT-proBNP)-guided therapy with those of intensive clinical management and with usual care (UC) on clinical outcomes in chronic symptomatic heart failure.

Background: Initial trial results suggest titration of therapy guided by serial plasma B-type natriuretic peptide levels improves outcomes in patients with chronic heart failure, but the concept has not received widespread acceptance. Accordingly, we conducted a longer-term study comparing the effects of NT-proBNP–guided therapy with those of intensive clinical management and with UC of patients with heart failure.

Methods: Three hundred sixty-four patients admitted to a single hospital with heart failure were randomly allocated 1:1:1 (stratified by age) to therapy guided by NT-proBNP levels or by intensive clinical management, or according to UC. Treatment strategies were applied for 2 years with follow-up to 3 years.

Results: One-year mortality was less in both the hormone- (9.1%) and clinically-guided (9.1%) groups compared with UC (18.9%; p = 0.03). Three-year mortality was selectively reduced in patients 75 years of age receiving hormone-guided treatment (15.5%) compared with their peers receiving either clinically managed treatment (30.9%; p = 0.048) or UC (31.3%; p = 0.021).

Conclusions: Intensive management of chronic heart failure improves 1-year mortality compared with UC. Compared with clinically guided treatment and UC, hormone-guided treatment selectively improves longer-term mortality in patients 75 years of age. (NT-proBNP–Assisted Treatment To Lessen Serial Cardiac Readmissions and Death [BATTLESCARRED]; Australian New Zealand Clinical Trials Registry 12605000735651)

Key Words: NT-proBNP • chronic heart failure • survival

Abbreviations and Acronyms

ACEI = angiotensin-converting enzyme inhibitor

ARB = angiotensin receptor blocker

BB = beta-adrenergic blocker

BNP = B-type natriuretic peptide

CG = clinically guided

CHF = chronic heart failure

LVEF = left ventricular ejection fraction

NT-proBNP = N-terminal pro–B-type natriuretic peptide

NYHA = New York Heart Association

UC = usual care