Level 1: Likely reliable evidence

B-type natriuretic peptide (BNP) as well as its N-terminal fragment (NT-proBNP) can provide useful diagnostic and prognostic information in patients with acute dyspnea and chronic heart failure. Prognosis tends to be better in patients whose BNP levels decrease in response to treatment. A recent systematic review offers evidence that medical treatment titrated in accordance with BNP or NT-proBNP levels reduces mortality in chronic heart failure (Am Heart J. 2009;158:422-430). BNP-guided treatment was compared with usual care guided primarily by clinical symptoms in 1,627 patients with heart failure. Follow-up ranged from six to 18 months. Patients receiving BNP-guided treatment had a significant reduction in all-cause mortality (hazard ratio 0.69, 95% CI 0.55-0.86), with an NNT of 12-40 for one year, assuming 80% survival in the control group. The benefit was observed primarily in patients younger than 75 years in two trials that stratified patients by age. BNP guidance was associated with increased use of ACE inhibitors, angiotensin receptor blockers, beta blockers, and aldosterone antagonists but not diuretics.