What is the initial treatment for patients with elevated N-terminal pro b-type natriuretic peptide (NTproBNP) levels indicative of heart failure?

Initial Treatment for Patients with Elevated NT-proBNP Levels Indicative of Heart Failure

For patients with elevated NT-proBNP levels indicative of heart failure, the initial treatment should include ACE inhibitors and beta-blockers as first-line therapy, with diuretics added for symptom management. 1

Diagnostic Confirmation and Assessment

Before initiating treatment, confirm the diagnosis using:

• Age-stratified NT-proBNP thresholds:

  • <50 years: >450 ng/L
  • 50-75 years: >900 ng/L

  • 75 years: >1800 ng/L 2

• Echocardiography to assess cardiac structure and function, particularly to determine if the patient has:

  • Heart failure with reduced ejection fraction (HFrEF)
  • Heart failure with preserved ejection fraction (HFpEF) 2

First-Line Pharmacological Treatment

For HFrEF:

1. ACE inhibitors and beta-blockers should be initiated simultaneously as first-line therapy 1

   • Titrate to maximum tolerated doses
   • Monitor blood pressure, heart rate, and renal function

2. Diuretics (typically loop diuretics like furosemide)

   • Add for patients with fluid overload and congestion
   • Dose according to clinical evidence of volume overload 2

3. Mineralocorticoid receptor antagonists (e.g., spironolactone)

   • Add as second-line therapy in patients who remain symptomatic despite optimal ACE inhibitor and beta-blocker therapy 1

For HFpEF:

• Treatment is more challenging as there are fewer evidence-based therapies
• Focus on symptom management and treatment of comorbidities
• SGLT2 inhibitors have shown benefit and should be considered 2

Advanced Pharmacological Options

1. Sacubitril/valsartan (ARNI)

   • Consider in patients with HFrEF who remain symptomatic despite optimal therapy
   • Has been shown to reduce NT-proBNP levels and improve cardiovascular outcomes 3
   • Contraindicated with concurrent ACE inhibitor use (requires 36-hour washout period) 3

2. Angiotensin Receptor Blockers (ARBs)

   • Alternative for patients who cannot tolerate ACE inhibitors 1

3. Combination therapy with nitrates and hydralazine

   • Consider as an alternative second-line therapy 1

Monitoring and Follow-up

• Regular monitoring of:

  • Blood pressure and heart rate
  • Renal function and electrolytes (particularly potassium)
  • Daily weight measurements 2

• Serial NT-proBNP measurements can help assess treatment effectiveness

  • A reduction of >30% indicates good response to treatment 2
  • However, routine serial measurements are only recommended for selected patients receiving specialist care 1

Common Pitfalls and Caveats

• Age considerations: Treatment benefits may vary by age. The BATTLESCARRED trial showed that NT-proBNP-guided treatment improved mortality in patients ≤75 years but not in older patients 4

• Renal function: NT-proBNP levels can be elevated in renal dysfunction independent of heart failure severity; adjust interpretation accordingly 2

• Obesity: Can lower NT-proBNP values, potentially masking volume overload; use lower cutoff values in patients with BMI >35 kg/m² 2

• Medication titration: The PRIMA study showed that while NT-proBNP-guided therapy increased medication use, it did not significantly improve clinical outcomes compared to standard care 5

• Avoid concurrent ACE inhibitor and ARB use: This combination increases adverse effects without substantial benefit 1

By following this treatment algorithm, clinicians can effectively manage patients with elevated NT-proBNP levels indicative of heart failure, focusing on evidence-based therapies that improve morbidity, mortality, and quality of life.