NT-proBNP as a risk stratification tool for the management of acute decompensated heart failure

The burden of heart failure (HF) remains high, with worrisome morbidity and mortality rates for patients hospitalized for acute decompensated heart failure (ADHF). The natriuretic peptides, BNP and the inactive N-terminal fragment of its precursor proBNP (NT-proBNP), which are released in response to cardiac wall stretch, are used for both diagnostic and prognostic purposes. Prognostication is especially important, because it allows clinicians to triage patients during and after hospitalization. This thesis aimed to unravel the role of NT-proBNP in the risk stratification and management of these high-risk patients. First, we build a simple, yet robust bedside discharge score, the ELAN-HF score (European coLlaboration on Acute decompeNsated Heart Failure), incorporating NT-proBNP levels at discharge as well as the dynamic change during hospitalization, predicting 6-months all-cause mortality. Additionally, other important risk factors of prognosis in ADHF were compared with NT-proBNP levels. Moreover, we studied a relatively unknown area of NT-proBNP use for prognosis and possibly management, as it concerns patients with preserved ejection fraction (HFpEF). Finally, the use of NT-proBNP as a guiding tool for patients hospitalized for ADHF was tested by conducting an international randomized study on in-hospital guidance of HF therapy by predefined NT-proBNP target. The aim was to decrease mortality and HF readmission rates 6 months after discharge, however the study showed that NT-proBNP-guided therapy did not improve outcome. Therefore, we conclude that natriuretic peptides in patients hospitalized for ADHF are to be used as a risk stratification tool at discharge without any consequence for follow-up or guiding strategies.