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Table 4 Summary of findings table

From: B-type natriuretic peptide-guided therapy for heart failure (HF): a systematic review and meta-analysis of individual participant data (IPD) and aggregate data

Serial B-type natriuretic peptide (BNP) blood testing to guide up-titration of medication compared to symptom-guided up-titration of medication in patients with heart failure (HF)
Patient or population: patients with heart failure (HF)
Setting: secondary care
Intervention: serial B-type natriuretic peptide (BNP) blood testing to guide up-titration of medication
Comparison: symptom-guided up-titration of medication
Outcome
No. of participants (studies)
Relative effect (95% CI) Anticipated absolute effects (95% CI) Certainty What happens
Without serial B-type natriuretic peptide (BNP) blood testing to guide up-titration of medication With serial B-type natriuretic peptide (BNP) blood testing to guide up-titration of medication Difference
All-cause mortality follow up: range 3 to 30 months
No. of participants: 3691 (13 RCTs)
HR 0.87 (0.71 to 1.01) 19.9% 17.5% (14.6 to 20.1) 2.3% fewer (5.3 fewer to 0.2 more) Lowa,b BNP-guided therapy may result in little to no difference in all-cause mortality.
Death related to HF follow up: range 12 to 15 months
No. of participants: 488 (2 RCTs)
Two studies reported death related to HF. There were no significant differences between the BNP-guided therapy and the symptom-guided therapy groups in either study (3/110 vs. 9/110, respectively, and 21/140 vs. 16/128, respectively). Very low a,b,c It is uncertain whether BNP-guided therapy prevents death related to HF because the quality of the evidence is very low.
Cardiovascular death follow up: range 9 to 23 months
No. of participants: 1909 (5 RCTs)
OR 0.88 (0.67 to 1.16) 13.7% 12.3% (9.6 to 15.6) 1.4% fewer (4.1 fewer to 1.9 more)
Low a,b
BNP-guided therapy may lead to little or no difference in cardiovascular death.
All-cause hospitalisation follow up: range 3 to 30 months
No. of participants: 984 (7 RCTs)
HR 0.97 (0.85 to 1.10) 57.2% 56.1% (51.4 to 60.7) 1.1% fewer (5.8 fewer to 3.5 more) Lowa,b BNP-guided therapy may result in little or no difference in all-cause hospitalisation.
HF hospitalisation follow up: range 9 to 30 months
No. of participants: 2655 (8 RCTs)
HR 0.81 (0.68 to 0.98) 34.1% 28.6% (24.7 to 33.5) 5.4% fewer (9.4 fewer to 0.6 fewer) Very lowa,b,d It is uncertain whether BNP-guided therapy reduces hospital admissions for HF because the quality of evidence is very low.
Adverse events follow up: range 9 to 18 months
No. of participants: 2055 (5 RCTs)
OR 1.29 (1.04 to 1.60) 24.4% 29.4% (25.1 to 34.1) 5.0% more (0.7 more to 9.7 more) Lowa,b BNP-guided therapy may lead to an increase in adverse events.
Quality of life follow up: range 10 to 30 months
No. of participants: 1884 (6 RCTs)
Six studies reported data on QoL (five used the Minnesota Living with Heart Failure Questionnaire and one used SF-36) in their published report. Data could not be combined in a meta-analysis because changes in QoL were reported differently in each study. Only one study reported a significant improvement in QoL in the BNP-guided therapy group vs. symptom guided therapy group; five reported no difference between groups. Three additional studies included a statement in their published report saying that that there was no difference in QoL between groups and one included a statement saying that results of QoL analyses were not reported in the manuscript. Very lowa,b,c It is uncertain whether BNP-guided therapy improves quality of life because the quality of the evidence is very low.
  1. *The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI)
  2. CI confidence interval; HR hazard ratio; OR odds ratio
  3. GRADE Working Group grades of evidence
  4. High certainty: we are very confident that the true effect lies close to that of the estimate of the effect
  5. Moderate certainty: we are moderately confident in the effect estimate; the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different
  6. Low certainty: our confidence in the effect estimate is limited; the true effect may be substantially different from the estimate of the effect
  7. Very low certainty: we have very little confidence in the effect estimate; the true effect is likely to be substantially different from the estimate of effect
  8. aNone of the RCTs were blinded (either patients or healthcare professionals) so at risk of bias due to deviations from intended interventions (performance bias)
  9. bMost RCTs did not include patients with HF with preserved ejection fraction (HFpEF). Women and patients > = 75 years were also under-represented
  10. cNarrative synthesis was conducted; estimates are not precise
  11. dI2 statistic (46%) suggests moderate heterogeneity