Medical University of South Carolina and Ralph H. Johnson Veterans Administration Medical Center, Charleston, South Carolina.
Brigham and Women's Hospital, Boston, Massachusetts.
J Am Coll Cardiol. 2016 Dec 6;68(22):2425-2436. doi: 10.1016/j.jacc.2016.09.931.
Natriuretic peptides (NP) have prognostic value in heart failure (HF), although the clinical importance of changes in NP from baseline is unclear.
The authors assessed whether a reduction in N-terminal pro-B-type NP (NT-proBNP) was associated with a decrease in HF hospitalization and cardiovascular mortality (primary endpoint) in patients with HF and reduced ejection fraction, whether treatment with sacubitril/valsartan reduced NT-proBNP below specific partition values more than enalapril, and whether the relationship between changes in NT-proBNP and changes in the primary endpoint were dependent on assigned treatment.
In PARADIGM-HF (Prospective Comparison of ARNI [Angiotensin Receptor-Neprilysin Inhibitor] with ACEI [Angiotensin-Converting-Enzyme Inhibitor] to Determine Impact on Global Mortality and Morbidity in Heart Failure Trial), baseline NT-proBNP was measured in 2,080 patients; 1,292 had baseline values >1,000 pg/ml and were reassessed at 1 and 8 months. We related change in NT-proBNP to outcomes.
One month after randomization, 24% of the baseline NT-proBNP levels >1,000 pg/ml had fallen to ≤1,000 pg/ml. Risk of the primary endpoint was 59% lower in patients with a fall in NT-proBNP to ≤1,000 pg/ml than in those without such a fall. In sacubitril/valsartan-treated patients, median NT-proBNP was significantly lower 1 month after randomization than in enalapril-treated patients, and it fell to ≤1,000 pg/ml in 31% versus 17% of patients treated with sacubitril/valsartan and enalapril, respectively. There was no significant interaction between treatment and the relationship between change in NT-proBNP and the subsequent risk of the primary endpoint.
Patients who attained a significant reduction in NT-proBNP had a lower subsequent rate of cardiovascular death or HF hospitalization independent of the treatment group. Treatment with sacubitril/valsartan was nearly twice as likely as enalapril to reduce NT-proBNP to values ≤1,000 pg/ml. (Prospective Comparison of ARNI [Angiotensin Receptor-Neprilysin Inhibitor] with ACEI [Angiotensin-Converting-Enzyme Inhibitor] to Determine Impact on Global Mortality and Morbidity in Heart Failure Trial) [PARADIGM-HF]; NCT01035255.).
利钠肽（NP）在心衰（HF）中有预后价值，尽管 NP 从基线的变化的临床意义尚不清楚。
作者评估 HF 和射血分数降低的患者中 N 末端 pro-B 型利钠肽（NT-proBNP）的降低是否与 HF 住院和心血管死亡率的降低相关（主要终点），与依那普利相比，沙库巴曲缬沙坦是否能将 NT-proBNP 降低到特定的分区值以下，以及 NT-proBNP 的变化与主要终点变化之间的关系是否取决于分配的治疗。
在 PARADIGM-HF（血管紧张素受体-脑啡肽酶抑制剂与血管紧张素转换酶抑制剂治疗心力衰竭的前瞻性比较以确定对全球死亡率和发病率的影响试验）中，2080 名患者测量了基线 NT-proBNP；1292 名患者的基线值>1000 pg/ml，并在 1 和 8 个月时重新评估。我们将 NT-proBNP 的变化与结果相关联。
随机分组后 1 个月，基线 NT-proBNP 水平>1000 pg/ml 的患者中有 24%下降至≤1000 pg/ml。与未发生此类下降的患者相比，NT-proBNP 下降至≤1000 pg/ml 的患者主要终点的风险降低 59%。与依那普利治疗的患者相比，随机分组后 1 个月沙库巴曲缬沙坦治疗的患者中位 NT-proBNP 明显更低，且沙库巴曲缬沙坦治疗组和依那普利治疗组分别有 31%和 17%的患者 NT-proBNP 下降至≤1000 pg/ml。治疗与 NT-proBNP 变化与随后主要终点风险之间的关系之间无显著交互作用。
NT-proBNP 显著降低的患者，不论治疗组，随后心血管死亡或 HF 住院的发生率较低。与依那普利相比，沙库巴曲缬沙坦将 NT-proBNP 降低至≤1000 pg/ml 的可能性几乎高出两倍。（血管紧张素受体-脑啡肽酶抑制剂与血管紧张素转换酶抑制剂治疗心力衰竭的前瞻性比较以确定对全球死亡率和发病率的影响试验）[PARADIGM-HF]；NCT01035255。）
