title: Challenging the two concepts in determining the appropriate pre-discharge N-terminal pro-brain natriuretic peptide treatment target in acute decompensated heart failure patients: absolute or relative discharge levels?
abstract: OBJECTIVE
  NT-proBNP is a strong predictor for readmissions and mortality in acute decompensated heart failure (ADHF) patients. We assessed whether absolute or relative NT-proBNP levels should be used as pre discharge treatment target.
  
  
  RESULTS
  Our study population was assembled from seven ADHF cohorts. We defined absolute (<1500, <3000, <5000, and <15 000 ng/L) and relative NT-proBNP targets (>30, >50, and >70%). Population attributable risk fraction (PARF) is the proportion of all-cause 6-month mortality in the population that would be reduced if all patients attain the NT-proBNP target. PARF was determined for each target as well as the percentage of patients attaining the NT-proBNP target. Attainability was investigated by logistic regression analysis. A total of 1266 patients [age 74 (64-80), 60% male] was studied. For every absolute NT-proBNP level, a corresponding percentage reduction was found that resulted in similar PARFs. The highest PARF (∼60-70%) was observed for <1500 or >70%, but attainability was low (27% and 22%, respectively). The strongest predictor for not attaining these targets was admission NT-proBNP. In admission NT-proBNP tertiles, PARFs were significantly different for absolute, but not for relative targets.
  
  
  CONCLUSIONS
  In an ADHF population, pre-discharge absolute or relative NT-proBNP targets may both be useful as they have similar effects on PARF. However, depending on admission NT-proBNP, absolute targets show varying PARFs, while PARFs for relative targets were similar. A relative target is predicted to reduce mortality consistently across the whole spectrum of ADHF patients, while this is not the case using a single absolute target.
authors.affiliation: Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands.
authors.forename: Susan
authors.initials: S
authors.lastname: Stienen
authors.affiliation: Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands.
authors.forename: Khibar
authors.initials: K
authors.lastname: Salah
authors.affiliation: Department of Cardiology, Maastricht University Medical Center, The Netherlands.
authors.forename: Luc W M
authors.initials: LW
authors.lastname: Eurlings
authors.affiliation: Department of Internal Medicine, Centro Hospitalar de S. João, University of Porto Medical School, Porto, Portugal.
authors.forename: Paulo
authors.initials: P
authors.lastname: Bettencourt
authors.affiliation: Department of Internal Medicine, Centro Hospitalar de S. João, University of Porto Medical School, Porto, Portugal.
authors.forename: Joana M
authors.initials: JM
authors.lastname: Pimenta
authors.affiliation: Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Italy.
authors.forename: Marco
authors.initials: M
authors.lastname: Metra
authors.affiliation: Department of Cardiology, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain.
authors.forename: Antoni
authors.initials: A
authors.lastname: Bayes-Genis
authors.affiliation: Department of Internal Medicine and Emergency, Careggi University Hospital, Florence, Italy.
authors.forename: Valerio
authors.initials: V
authors.lastname: Verdiani
authors.affiliation: Department of Cardiology, Azienda Istituti Ospitalieri di Cremona, Cremona, Italy.
authors.forename: Luca
authors.initials: L
authors.lastname: Bettari
authors.affiliation: Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Italy.
authors.forename: Valentina
authors.initials: V
authors.lastname: Lazzarini
authors.affiliation: Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands.
authors.forename: Jan P
authors.initials: JP
authors.lastname: Tijssen
authors.affiliation: Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands.
authors.forename: Yigal M
authors.initials: YM
authors.lastname: Pinto
authors.affiliation: Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands.
authors.forename: Wouter E M
authors.initials: WE
authors.lastname: Kok
mesh_terms: D000208:Acute Disease; D000368:Aged; D000369:Aged, 80 and over; D015415:Biomarkers / Q000097:blood; D002423:Cause of Death / Q000639:trends; D018450:Disease Progression; D005260:Female; D005500:Follow-Up Studies; D006333:Heart Failure / Q000097:blood* / Q000188:drug therapy / Q000401:mortality; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D008297:Male; D008875:Middle Aged; D020097:Natriuretic Peptide, Brain / Q000097:blood*; D010351:Patient Discharge; D010359:Patient Readmission / Q000639:trends; D010446:Peptide Fragments / Q000097:blood*; D011174:Portugal / Q000453:epidemiology; D011379:Prognosis; D011446:Prospective Studies; D011498:Protein Precursors; D018570:Risk Assessment / Q000379:methods*; D015996:Survival Rate / Q000639:trends; D013997:Time Factors
chemical_list: D015415:Biomarkers; D010446:Peptide Fragments; D011498:Protein Precursors; C109794:pro-brain natriuretic peptide (1-76); D020097:Natriuretic Peptide, Brain
keywords: Absolute discharge level; Acute decompensated heart failure; NT-proBNP; Relative reduction