Achieving NP predischarge thresholds associated with reduced heart failure mortality and readmission

1. The majority of studies report a statistically significant reduction in the risk for death in acute decompensated heart failure (ADHF) patients when using natriuretic peptide (NP) threshold as a criterion for discharge.

2. Studies reviewed suggest a potential role for brain-type NP (BNP) and amino-terminal pro-brain-type NP (NT-proBNP) levels to aid health care providers in assessing quality of inpatient care and improving patient outcomes after discharge.

Evidence Rating Level: 1 (Excellent)

Study Rundown: ADHF is a serious cause of hospitalization. In the United States, ADHF costs the health care system over $16 billion each year. While guidelines are in place for inpatient treatment, the readmission rate is high—over half of all patients treated for ADHF return within 6 months with similar symptoms. One of the factors contributing to this readmission rate is untimely discharge; as physical examination findings are variable, many inpatient treatments are stopped too early. NP may provide key information for determining patient readiness for discharge. The authors of this study aimed to conduct a systematic review to examine the effect of using NP thresholds as a discharge criterion on readmission and mortality rates in patients hospitalized for ADHF. This review has several limitations. Largely, the quality of literature on this topic was mostly restricted to cohort or case-control studies with poorly defined exposures and outcomes. Overall, the authors concluded that low-strength evidence indicates an association between achieving NP predischarge thresholds and reduced ADHF mortality and readmission.

Click to read the study in the Annals of Internal Medicine

Relevant Reading: Early Management of Patients with Acute Heart Failure: State of the Art and Future Directions

In-Depth [systematic review]: In this systematic review, 70 full text articles were assessed and 44 were identified for data extraction. These studies included 1 randomized controlled trial, in addition to several quasi-experimental studies, cohort studies, and case-control studies. No meta-analysis was performed, as significant clinical heterogeneity was observed between studies. Furthermore, most studies were attributed a high risk of bias due to failing to meet criteria regarding comparability and definition of the exposure or outcome. These studies did not frequently adjust for critical confounders, making comparison difficult. In general, 14 of 16 studies reported a statistically significant reduction in the risk of death. Furthermore, 3 of 5 reported statistically significant reductions in readmissions. The most commonly recommended threshold change in NT-proBNP was 30% from admission to discharge, in order to reduce mortality and readmission. The majority of studies examining BNP thresholds also recommended a threshold of 30%.

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