Showing papers in "Yearbook of Cardiology in 2010"

BNP-Guided vs Symptom-Guided Heart Failure Therapy: The Trial of Intensified vs Standard Medical Therapy in Elderly Patients With Congestive Heart Failure (TIME-CHF) Randomized Trial

Abstract: Background: Therapy for congestive heart failure (CHF) is often adjusted based on symptoms. It is not known whether brain natriuretic peptide (BNP) would be a better tool to guide heart failure therapy. Objective: To compare the use of symptoms versus BNP in the adjustment of heart failure therapies over 18 months. Design: Single-blind, randomized, controlled trial. Participants: Patients aged ≥60 years with New York Heart Association (NYHA) class II or greater symptoms on therapy, a hospitalization within the previous year for CHF, and BNP >400 pg/mL if age was <75 years or >800 pg/mL if age was ≥75 years. Patients were recruited to 15 centers in Switzerland and Germany. Methods: 622 patients (80% with systolic heart failure) were divided into 2 age groups: 60 to 74 years and ≥75 years. Patients were randomized to medication adjustment guided by symptoms or BNP. Medications changes were based on a guideline-driven algorithm. Goals of therapy were NYHA class II symptoms or less or BNP <2 times the upper limit of normal. Patients were evaluated at baseline and at 1, 3, 6, 12, and 18 months. The primary end points were survival free of hospitalization and quality of life at 18 months. Results: Patients in the BNP-guided group were more likely to have their medication uptitrated than those in the symptom-guided group. Survival free of hospitalization was no different in the 2 treatment groups, but survival free of heart failure hospitalization was significantly less in the 60to 74-year-old BNP-guided group. Quality-of-life measures improved in both groups but were not significantly different. Serious side effects were no different in the 2 treatment groups. Conclusions: Treatment guided by BNP does not reduce survival free of hospitalization or quality of life, but does reduce hospitalizations due to heart failure in patients aged 60 to 74 years with CHF. Reviewer's Comments: This study suggests that physicians may need to be more aggressive in uptitrating medications in patients with heart failure. BNP-guided therapy may be a useful strategy in some patients, especially those aged <75 years. (Reviewer-Deborah L. Greenberg, MD).