Limited value of NT-proBNP as a prognostic marker of all-cause mortality in patients with heart failure with preserved and mid-range ejection fraction in primary care: A report from the swedish heart failure register

Abstract

Aim: The prognostic value of natriuretic peptides in the management of heart failure (HF) patients with ejection fraction (EF) <40% is well established, but is less known for those with EF ≥40% managed in primary care (PC). Therefore, the aim of this study is to describe the prognostic significance of plasma NT-proBNP in such patients managed in PC.

Subjects: We included 924 HF patients (48% women) with EF ≥40% and NT-proBNP registered in the Swedish Heart Failure Registry. Follow-up was 1100 ± 687 days.

Results: One-, three- and five-year mortality rates were 8.1%, 23.9% and 44.7% in patients with EF 40–50% (HFmrEF) and 7.3%, 23.6% and 37.2% in patients with EF ≥50% (HFpEF) (p = 0.26). Patients with the highest mean values of NT-proBNP had the highest all-cause mortality but wide standard deviations (SDs). In univariate regression analysis, there was an association only between NT-proBNP quartiles and all-cause mortality. In HFmrEF patients, hazard ratio (HR) was 1.96 (95% CI 1.60–2.39) p < 0.0001) and in HFpEF patients, HR was 1.72 (95% CI 1.49–1.98) p < 0.0001). In a multivariate Cox proportional hazard regression analysis, adjusted for age, NYHA class, atrial fibrillation and GFR class, this association remained regarding NT-proBNP quartiles [HR 1.83 (95% CI 1.38–2.44), p < 0.0001] and [HR 1.48 (95% CI 1.16–1.90), p = 0.0001], HFmrEF and HFpEF, respectively.

Conclusion: NT-proBNP has a prognostic value in patients with HF and EF ≥40% managed in PC. However, its clinical utility is limited due to high SDs and the fact that it is not independent in this population which is characterized by high age and much comorbidity.

Key points

• It is uncertain whether NT-proBNP predicts risk in heart failure with preserved ejection fraction (EF > 40%, HFpEF) managed in primary care.

• We show that high NT-proBNP predicts increased all-cause mortality in HFpEF-patients managed in primary care.

• The clinical use is however limited due to large standard deviations, many co-morbidities and high age.

• Many of these co-morbidities contribute to all-cause mortality and management of these patients should also focus on these co-morbidities.

Keywords:

• Heart failure
• EF ≥40%
• primary care
• NT-proBNP
• prognosis

Acknowledgements

The authors thank all local center investigators and study personnel for data collection and entry. The authors thank Alan Crozier for professional language editing.

Access to data

BE, PW and ME had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Disclosure statement

There are no conflicts of interest related to the work submitted. Outside the work submitted, there are the following potential conflicts of interest: BE: none declared; PW: none declared; PN: none declared; UD: research grants to author’s institution from AstraZeneca Inc. and speaker’s and consulting honoraria from Novartis Inc. and AstraZeneca Inc.; LHL: research grants to author’s institution, speakers and consulting fees, Astra-Zeneca, Inc., Novartis, Inc.; ME: none declared.