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Beyond Assumptions: NT-proBNP Rise and Diuretic Strategies in HFrEF Therapy Up-Titration
Session:
Sessão de Posters 37 - Insuficiência cardíaca - Terapêutica farmacológica
Speaker:
Diogo Rosa Ferreira
Congress:
CPC 2024
Topic:
D. Heart Failure
Theme:
10. Chronic Heart Failure
Subtheme:
10.6 Chronic Heart Failure - Clinical
Session Type:
Cartazes
FP Number:
---
Authors:
Diogo Ferreira; Catarina Gregório; Ana Beatriz Garcia; Ana Francês; Fátima Salazar; Rafael Santos; Joana Rigueira; Doroteira Silva; Nuno Lousada; Fausto Pinto; Dulce Brito; João Agostinho
Abstract
<p style="text-align:justify"><strong>Introduction</strong></p> <p style="text-align:justify">In patients with Heart failure and Reduced Ejection Fraction (HFrEF), NT-proBNP may rise during guideline-directed therapy up-titration. The STRONG-HF trial authors assumed that NT-proBNP increase between visits predicted worse prognosis, suggesting caution in up-titrating beta-blocker (BB) and considering diuretic escalation. Yet, this assumption lacks testing, and evidence linking NT-proBNP elevation during up-titration to a worse prognosis is absent.</p> <p style="text-align:justify"> </p> <p style="text-align:justify"><strong>Methods:</strong></p> <p style="text-align:justify">Retrospective, single-center study on HFrEF patients followed at an HF-specialized outpatient clinic since 2019. Two groups were formed: patients that had more than 10% increase in NT-proBNP at least once between up-titration visits and patients that had stable (<10% increase) or decreasing NT-proBNP between visits. A composite outcome of all-cause death and HF-hospitalizations (HFH) was compared at 3 years follow-up. Diuretic and beta-blocker (BB) titration was evaluated in patients that had an increase in NT-proBNP.</p> <p style="text-align:justify"> </p> <p style="text-align:justify"><strong>Results:</strong></p> <p style="text-align:justify">Of the 154 patients studied, 24.4% were female, 46.7% were ischemic, and 41.7% had dilated cardiomyopathy, mean age was 64.3±14,2 years. Patients had an average of 3.4 up-titration visits, and it took around 6,8 weeks to reach guideline-recommended doses. Seventy-seven patients (49.4%) experienced an NT-proBNP increase at least once, while 79 patients (50.6%) did not. The two groups showed similarities in sex, age, eGFR, baseline NYHA class and NT-proBNP.</p> <p style="text-align:justify">Composite outcome at 3 years was 4,1 times more likely to happen in the NT-proBNP rise group (HR: 4.06, CI 95%: 1.10-15.02, p=0.02). The difference was mainly driven by HFH. Within the NT-proBNP rise group, 24.5% of patients had their diuretic dose increased during up-titration, with a mean furosemide end-dose of 66mg. In contrast, 75.5% of patients either maintained or reduced their diuretic dose, resulting in a mean furosemide end-dose of 17mg. Those requiring an increase in diuretics during up-titration faced a 3.8 times greater risk of the composite outcome (HR: 3.82, CI 95%: 1.10-13.31, p=0.035). In contrast, changing or maintaining BB dose in patients in the NTproBNP increase group did not impacted prognosis.</p> <p style="text-align:justify"> </p> <p style="text-align:justify"><strong>Conclusion:</strong></p> <p style="text-align:justify">An increase exceeding 10% in NT-proBNP during up-titration visits in patients with HFrEF signals a higher risk of death or HFH. Importantly, contrary to what was suggested, increasing diuretic dosage not only failed to improve outcomes in these patients but it correlated with a worse prognosis. It seems that the clinical need to up-titrate furosemide – clinical congestion - indicates a more severe prognosis, overshadowing the importance of the NT-proBNP increase in predicting adverse outcomes.</p> <p style="text-align:justify"> </p>
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