From the Guidelines
For a patient with elevated N-terminal pro b-type natriuretic peptide (NT-proBNP) levels, treatment should focus on optimizing heart failure therapy with medications such as ACE inhibitors, beta-blockers, and mineralocorticoid receptor antagonists, as recommended by the 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 1. The elevated NT-proBNP levels indicate worsening heart failure, requiring prompt intervention to reduce morbidity, mortality, and improve quality of life.
Key Treatment Options
- ACE inhibitors or ARBs: First-line medications for heart failure, with ACE inhibitors recommended for patients who can tolerate them, and ARBs for those who cannot 1.
- Beta-blockers: Should be initiated at low doses and gradually increased to improve symptoms and reduce the risk of heart failure hospitalization and death 1.
- Mineralocorticoid receptor antagonists (MRAs): Recommended for patients with heart failure with reduced ejection fraction to reduce the risk of heart failure hospitalization and death 1.
- Diuretics: Essential for managing fluid overload symptoms, with loop diuretics such as furosemide recommended for patients with signs and/or symptoms of congestion 1.
- Sacubitril/valsartan: May be considered as a replacement for an ACE inhibitor to further reduce the risk of heart failure hospitalization and death in ambulatory patients with heart failure with reduced ejection fraction who remain symptomatic despite optimal treatment 1.
Additional Considerations
- Ivabradine: May be considered to reduce the risk of heart failure hospitalization or cardiovascular death in symptomatic patients with left ventricular ejection fraction ≤35%, in sinus rhythm, and a resting heart rate ≥70 bpm despite treatment with an evidence-based dose of beta-blocker 1.
- Hydralazine and isosorbide dinitrate: May be considered to reduce the risk of heart failure hospitalization and death in symptomatic patients with left ventricular ejection fraction <45% combined with a dilated left ventricle in NYHA Class III-IV despite treatment with an ACE inhibitor, a beta-blocker, and an MRA 1.
- Lifestyle modifications: Sodium restriction, fluid restriction, daily weight monitoring, and regular follow-up are crucial for managing heart failure and reducing morbidity and mortality.
From the FDA Drug Label
Sacubitril and valsartan tablets are a combination of sacubitril, a neprilisin inhibitor, and valsartan, an angiotensin II receptor blocker, and is indicated: to reduce the risk of cardiovascular death and hospitalization for heart failure in adult patients with chronic heart failure and reduced ejection fraction. (1. 1) for the treatment of symptomatic heart failure with systemic left ventricular systolic dysfunction in pediatric patients aged one year and older. Sacubitril and valsartan tablets reduces NT-proBNP and is expected to improve cardiovascular outcomes. (1. 2)
The treatment option available for a patient with elevated NT-proBNP levels is sacubitril and valsartan tablets, which is indicated for the treatment of symptomatic heart failure with systemic left ventricular systolic dysfunction and reduces NT-proBNP levels, expected to improve cardiovascular outcomes 2.
- The recommended starting dosage for adults is 49 mg/51 mg orally twice daily, with a target maintenance dose of 97 mg/103mg orally twice daily.
- Doses should be adjusted every 2 to 4 weeks to the target maintenance dose, as tolerated by the patient.
From the Research
Treatment Options for Elevated NT-proBNP Levels
- NT-proBNP-guided care has been shown to reduce the incidence of worsening heart failure (WHF) and improve event-free survival in patients with chronic heart failure with reduced ejection fraction (HFrEF) 3
- Sacubitril/valsartan has been found to reduce heart failure hospitalizations, cardiovascular mortality, and all-cause mortality compared to renin-angiotensin-aldosterone system inhibitors in patients with heart failure 4
- Outpatient management of worsening chronic heart failure using intravenous diuretic treatment has been proposed as a strategy to reduce the burden on healthcare systems and improve patient satisfaction and quality of life 5
- Guideline-recommended medical therapy (GRMT) and prevention of first and recurring episodes of worsening heart failure are essential components of heart failure treatment 6
Medication Options
- Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) are commonly used to treat heart failure 4, 7
- Sacubitril/valsartan has been shown to have better clinical, intermediate, and renal outcomes in heart failure compared to ACEIs or ARBs 4
- ß-blockers and ACE-inhibitors can improve outcome and symptoms in heart failure patients with left ventricular dysfunction 7
Management Strategies
- Early and rapid administration of GRMT can help prevent first and recurring episodes of worsening heart failure 6
- Outpatient intravenous diuretic treatment can be used to manage worsening chronic heart failure in certain patients 5
- Hospital-at-home IV diuretic administration and day hospital care are alternative management strategies for worsening heart failure 5