title: Brain-Type Natriuretic Peptide and Amino-Terminal Pro-Brain-Type Natriuretic Peptide Discharge Thresholds for Acute Decompensated Heart Failure: A Systematic Review.
abstract: BACKGROUND
  Acute decompensated heart failure (ADHF) requiring hospitalization is associated with high postdischarge mortality and readmission rates.
  
  
  OBJECTIVE
  To examine the association between achieving predischarge natriuretic peptide (NP) thresholds and mortality and readmission rates in adults hospitalized for ADHF.
  
  
  METHODS
  Multiple databases from 1947 to October 2016 (English-language studies only).
  
  
  METHODS
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  Most studies failed to adjust for critical confounders and had inadequate definition or assessment of exposures and outcomes.
  
  
  CONCLUSIONS
  Low-strength evidence suggests an association between achieving NP predischarge thresholds and reduced ADHF mortality and readmission.
  
  
  BACKGROUND
  None.
authors.affiliation: From Perelman School of Medicine, University of Pennsylvania, and Penn Medicine Center for Evidence-based Practice, University of Pennsylvania Health System, Philadelphia, Pennsylvania.
authors.forename: Casey N
authors.initials: CN
authors.lastname: McQuade
authors.affiliation: From Perelman School of Medicine, University of Pennsylvania, and Penn Medicine Center for Evidence-based Practice, University of Pennsylvania Health System, Philadelphia, Pennsylvania.
authors.forename: Marisa
authors.initials: M
authors.lastname: Mizus
authors.affiliation: From Perelman School of Medicine, University of Pennsylvania, and Penn Medicine Center for Evidence-based Practice, University of Pennsylvania Health System, Philadelphia, Pennsylvania.
authors.forename: Joyce W
authors.initials: JW
authors.lastname: Wald
authors.affiliation: From Perelman School of Medicine, University of Pennsylvania, and Penn Medicine Center for Evidence-based Practice, University of Pennsylvania Health System, Philadelphia, Pennsylvania.
authors.forename: Lee
authors.initials: L
authors.lastname: Goldberg
authors.affiliation: From Perelman School of Medicine, University of Pennsylvania, and Penn Medicine Center for Evidence-based Practice, University of Pennsylvania Health System, Philadelphia, Pennsylvania.
authors.forename: Mariell
authors.initials: M
authors.lastname: Jessup
authors.affiliation: From Perelman School of Medicine, University of Pennsylvania, and Penn Medicine Center for Evidence-based Practice, University of Pennsylvania Health System, Philadelphia, Pennsylvania.
authors.forename: Craig A
authors.initials: CA
authors.lastname: Umscheid
mesh_terms: D006333:Heart Failure / Q000097:blood* / Q000401:mortality*; D006801:Humans; D020097:Natriuretic Peptide, Brain / Q000097:blood*; D010351:Patient Discharge; D010359:Patient Readmission; D010446:Peptide Fragments / Q000097:blood*; D012307:Risk Factors
chemical_list: D010446:Peptide Fragments; C109794:pro-brain natriuretic peptide (1-76); D020097:Natriuretic Peptide, Brain