Casey N. McQuade, MD; Marisa Mizus, MD, MS; Joyce W. Wald, DO; Lee Goldberg, MD, MPH; Mariell Jessup, MD; Craig A. Umscheid, MD, MSCE
Acknowledgment: The authors thank Matthew Mitchell, PhD (University of Pennsylvania Health System), and Frank Campbell (University of Pennsylvania Biomedical Library) for their contributions to our database search strategies. They did not receive compensation for their work.
Disclosures: Dr. Mizus reports grants from the Institute for Translational Medicine and Therapeutics of the Perelman School of Medicine at the University of Pennsylvania and from the National Institutes of Health during the conduct of the study. Dr. Goldberg reports personal fees from Medtronic and a grant from Respicardia outside the submitted work. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M16-1468.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer and Johnson & Johnson.
Reproducible Research Statement:Study protocol: See the Supplement. Statistical code: See the Methods section of the text. Data set: See the Appendix. Further requests can be sent to the authors (e-mail, email@example.com).
Requests for Single Reprints: Craig A. Umscheid, MD, MSCE, Penn Medicine Center for Evidence-based Practice, University of Pennsylvania Health System, 3535 Market Street, Mezzanine, Suite 50, Philadelphia, PA 19104; e-mail, firstname.lastname@example.org.
Current Author Addresses: Dr. McQuade: UPMC Montefiore Hospital, N-715, 200 Lothrop Street, Pittsburgh, PA 15213.
Dr. Mizus: Lankenau Medical Center, 100 East Lancaster Avenue, Wynnewood, PA 19096.
Drs. Wald, Goldberg, and Jessup: Perelman Center for Advanced Medicine, 3400 Civic Center Boulevard, East Pavilion, 2nd Floor, Philadelphia, PA 19104.
Dr. Umscheid: Penn Medicine Center for Evidence-based Practice, University of Pennsylvania Health System, 3535 Market Street, Mezzanine, Suite 50, Philadelphia, PA 19104.
Author Contributions: Conception and design: C.N. McQuade, M. Mizus, C.A. Umscheid.
Analysis and interpretation of the data: C.N. McQuade, M. Mizus, C.A. Umscheid.
Drafting of the article: C.N. McQuade, M. Mizus, C.A. Umscheid.
Critical revision of the article for important intellectual content: C.N. McQuade, M. Mizus, J.W. Wald, L. Goldberg, M. Jessup, C.A. Umscheid.
Final approval of the article: C.N. McQuade, M. Mizus, J.W. Wald, L. Goldberg, M. Jessup, C.A. Umscheid.
Provision of study materials or patients: C.A. Umscheid.
Statistical expertise: C.A. Umscheid.
Administrative, technical, or logistic support: C.A. Umscheid.
Collection and assembly of data: C.N. McQuade, M. Mizus, C.A. Umscheid.
Acute decompensated heart failure (ADHF) requiring hospitalization is associated with high postdischarge mortality and readmission rates.
To examine the association between achieving predischarge natriuretic peptide (NP) thresholds and mortality and readmission rates in adults hospitalized for ADHF.
Multiple databases from 1947 to October 2016 (English-language studies only).
Trials and observational studies that compared mortality and readmission outcomes between patients with ADHF achieving a specific predischarge NP goal and those not achieving the goal.
Two investigators independently extracted study characteristics and assessed study risk of bias. One author graded the overall strength of evidence, with review by a second author.
One randomized trial, 3 quasi-experimental studies, and 40 observational studies were identified. The most commonly used thresholds were a brain-type NP (BNP) level of 250 pg/mL or less or an amino-terminal pro–brain-type NP (NT-proBNP) decrease of at least 30%. Achievement of absolute BNP thresholds reduced postdischarge all-cause mortality (7 of 8 studies) and the composite outcome of mortality and readmission (12 of 14 studies). Achievement of percentage-change BNP thresholds reduced the composite outcome (5 of 6 studies), and achievement of percentage-change NT-proBNP thresholds reduced all-cause and cardiovascular mortality (2 of 4 studies) and the composite outcome (9 of 9 studies). All findings were low-strength. The randomized trial, assessed as having high risk of bias, suggested that a predischarge decrease in NT-proBNP level was associated with lower risk for the composite outcome. Two quasi-experimental studies and 5 observational studies had low risk of bias. Low-risk-of-bias studies had outcome estimates similar in magnitude and direction to estimates from high-risk-of-bias studies.
Most studies failed to adjust for critical confounders and had inadequate definition or assessment of exposures and outcomes.
Low-strength evidence suggests an association between achieving NP predischarge thresholds and reduced ADHF mortality and readmission.
McQuade CN, Mizus M, Wald JW, et al. Brain-Type Natriuretic Peptide and Amino-Terminal Pro–Brain-Type Natriuretic Peptide Discharge Thresholds for Acute Decompensated Heart Failure: A Systematic Review. Ann Intern Med. [Epub ahead of print 29 November 2016]166:180–190. doi: 10.7326/M16-1468
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Published: Ann Intern Med. 2017;166(3):180-190.
Published at www.annals.org on 29 November 2016
Cardiology, Endocrine and Metabolism, Heart Failure, Hospital Medicine, Neurology.
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