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BNP-guided vs symptom-guided heart failure therapy: the Trial of Intensified vs Standard Medical Therapy in Elderly Patients With Congestive Heart Failure (TIME-CHF) randomized trial Pfisterer M; Buser P; Rickli H; Gutmann M; Erne P; Rickenbacher P; Vuillomenet A; Jeker U; Dubach P; Beer H; Yoon SI; Suter T; Osterhues HH; Schieber MM; Hilti P; Schindler R; Brunner-La Rocca HPJAMA 2009[Jan]; 301 (4): 383-92CONTEXT: It is uncertain whether intensified heart failure therapy guided by N-terminal brain natriuretic peptide (BNP) is superior to symptom-guided therapy. OBJECTIVE: To compare 18-month outcomes of N-terminal BNP-guided vs symptom-guided heart failure therapy. DESIGN, SETTING, AND PATIENTS: Randomized controlled multicenter Trial of Intensified vs Standard Medical Therapy in Elderly Patients With Congestive Heart Failure (TIME-CHF) of 499 patients aged 60 years or older with systolic heart failure (ejection fraction < or = 45%), New York Heart Association (NYHA) class of II or greater, prior hospitalization for heart failure within 1 year, and N-terminal BNP level of 2 or more times the upper limit of normal. The study had an 18-month follow-up and it was conducted at 15 outpatient centers in Switzerland and Germany between January 2003 and June 2008. INTERVENTION: Uptitration of guideline-based treatments to reduce symptoms to NYHA class of II or less (symptom-guided therapy) and BNP level of 2 times or less the upper limit of normal and symptoms to NYHA class of II or less (BNP-guided therapy). MAIN OUTCOME MEASURES: Primary outcomes were 18-month survival free of all-cause hospitalizations and quality of life as assessed by structured validated questionnaires. RESULTS: Heart failure therapy guided by N-terminal BNP and symptom-guided therapy resulted in similar rates of survival free of all-cause hospitalizations (41% vs 40%, respectively; hazard ratio [HR], 0.91 [95% CI, 0.72-1.14]; P = .39). Patients' quality-of-life metrics improved over 18 months of follow-up but these improvements were similar in both the N-terminal BNP-guided and symptom-guided strategies. Compared with the symptom-guided group, survival free of hospitalization for heart failure, a secondary end point, was higher among those in the N-terminal BNP-guided group (72% vs 62%, respectively; HR, 0.68 [95% CI, 0.50-0.92]; P = .01). Heart failure therapy guided by N-terminal BNP improved outcomes in patients aged 60 to 75 years but not in those aged 75 years or older (P < .02 for interaction) CONCLUSION: Heart failure therapy guided by N-terminal BNP did not improve overall clinical outcomes or quality of life compared with symptom-guided treatment. TRIAL REGISTRATION: isrctn.org Identifier: ISRCTN43596477.|*Quality of Life[MESH]|Adrenergic beta-Antagonists/administration & dosage[MESH]|Aged[MESH]|Angiotensin Receptor Antagonists[MESH]|Angiotensin-Converting Enzyme Inhibitors/administration & dosage[MESH]|Biomarkers/blood[MESH]|Cardiovascular Agents/*administration & dosage[MESH]|Digoxin/administration & dosage[MESH]|Disease-Free Survival[MESH]|Diuretics/administration & dosage[MESH]|Female[MESH]|Germany[MESH]|Heart Failure/*blood/*drug therapy/physiopathology[MESH]|Humans[MESH]|Male[MESH]|Middle Aged[MESH]|Multivariate Analysis[MESH]|Natriuretic Peptide, Brain/*blood/drug effects[MESH]|Nitrates/administration & dosage[MESH]|Odds Ratio[MESH]|Peptide Fragments/*blood/drug effects[MESH]|Proportional Hazards Models[MESH]|Severity of Illness Index[MESH]|Stroke Volume[MESH]|Surveys and Questionnaires[MESH]|Switzerland[MESH]|Treatment Outcome[MESH] |
