***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: OBJECTIVES The purpose of this study was to compare the effects of N-terminal pro-B-type natriuretic peptide (NT-proBNP)-guided therapy with those of intensive clinical management and with usual care ( UC ) on clinical outcomes in chronic symptomatic heart failure . BACKGROUND Initial trial results suggest titration of therapy guided by serial plasma B-type natriuretic peptide levels improves outcomes in patients with chronic heart failure , but the concept has not received widespread acceptance . Accordingly , we conducted a longer-term study comparing the effects of NT-proBNP-guided therapy with those of intensive clinical management and with UC of patients with heart failure . METHODS Three hundred sixty-four patients admitted to a single hospital with heart failure were r and omly allocated 1:1:1 ( stratified by age ) to therapy guided by NT-proBNP levels or by intensive clinical management , or according to UC . Treatment strategies were applied for 2 years with follow-up to 3 years . RESULTS One-year mortality was less in both the hormone- ( 9.1 % ) and clinical ly-guided ( 9.1 % ) groups compared with UC ( 18.9 % ; p = 0.03 ) . Three-year mortality was selectively reduced in patients < or=75 years of age receiving hormone-guided treatment ( 15.5 % ) compared with their peers receiving either clinical ly managed treatment ( 30.9 % ; p = 0.048 ) or UC ( 31.3 % ; p = 0.021 ) . CONCLUSIONS Intensive management of chronic heart failure improves 1-year mortality compared with UC . Compared with clinical ly guided treatment and UC , hormone-guided treatment selectively improves longer-term mortality in patients < or=75 years of age . ( NT-proBNP-Assisted Treatment To Lessen Serial Cardiac Readmissions and Death [ BATTLESCARRED ] ; Australian New Zeal and Clinical Trials Registry 12605000735651 ) OBJECTIVES The aim of this multicenter study was to evaluate the prognostic impact of a therapeutic strategy using plasma brain natriuretic peptide ( BNP ) levels . BACKGROUND The prognosis of chronic heart failure ( CHF ) remains poor , even among patients treated in specialized departments . METHODS A total of 220 New York Heart Association functional class II to III patients considered optimally treated with angiotensin-converting enzyme inhibitors ( ACEIs ) , beta-blockers , and diuretics by CHF specialists were r and omized to medical treatment according to either current guidelines ( clinical group ) or a goal of decreasing BNP plasma levels < 100 pg/ml ( BNP group ) . Outpatient visits were scheduled every month for 3 months , then every 3 months . The primary combined end point was CHF-related death or hospital stay for CHF . RESULTS Both groups were similar for baseline clinical and biological characteristics . Left ventricular ejection fraction was slightly lower in the BNP group than in the clinical group ( 29.9 + /- 7.7 % vs. 31.8 + /- 8.4 % , p = 0.05 ) . At the end of the first 3 months , all types of drugs were changed more frequently in the BNP group . Mean dosages of ACEIs and beta-blockers were significantly higher in the BNP group ( p < 0.05 ) , whereas the mean increase in furosemide dosage was similar in both groups . During follow-up ( median 15 months ) , significantly fewer patients reached the combined end point in the BNP group ( 24 % vs. 52 % , p < 0.001 ) . CONCLUSIONS In optimally treated CHF patients , a BNP-guided strategy reduced the risk of CHF-related death or hospital stay for CHF . The result was mainly obtained through an increase in ACEI and beta-blocker dosages Although previous studies have documented adherence with certain established heart failure ( HF ) quality metrics in outpatient cardiology practice s , the extent to which there is conformity with other evidence -based , guideline -driven quality metrics in out patients with HF is unknown . IMPROVE HF is a prospect i ve cohort study design ed to characterize the current management of patients with chronic HF and left ventricular ejection fraction < or=35 % in outpatient cardiology practice s. We evaluated baseline data for conformity with adjunctive HF therapies including pneumococcal vaccinization , hydralazine/isosorbide dinitrate ( HYD/ISDN ) for Black patients , statin therapy , antiplatelet therapy , smoking-cessation counseling , low-density lipoprotein cholesterol levels  ( < 100 mg/dl ) , and  systolic blood pressure decrease  ( all patients < 140 mm Hg or [ optimal ] < 130 mm Hg ) . Baseline data were available for 15,381 patients attending 167 cardiology practice s. Patient characteristics included a median age 70 years , 71.0 % men , 9.1 % Black patients , 65.2 % with ischemic HF cause , and 61.7 % with a history of hypertension .  Mean adherences or documentations of adherence were only 7.3 % for HYD/ISDN and 1.0 % for pneumococcal vaccination .  Adherence to other adjunctive therapies ranged from 27.4 % to 82.0 % but none of the adjunctive treatment interventions were associated with high levels of adherence . Conformity with guideline -recommended , adjunctive HF therapies is deficient in the management of out patients with HF . Critical gaps in documentation or delivery of care exist , especially for the use of pneumococcal vaccination and HYD/ISDN . In conclusion , improved processes of care , better documentation , and /or increased measures to promote adherence to all primary and adjunctive therapies for HF are needed OBJECTIVES This study was design ed to investigate whether the addition of N-terminal pro-B-type natriuretic peptide-guided , intensive patient management ( BM ) to multidisciplinary care ( MC ) improves outcome in patients following hospitalization due to heart failure ( HF ) . BACKGROUND Patients hospitalized due to HF experience frequent rehospitalizations and high mortality . METHODS Patients hospitalized due to HF were r and omized to BM , MC , or usual care ( UC ) . Multidisciplinary care included 2 consultations from an HF specialist who provided therapeutic recommendations and home care by a specialized HF nurse . In addition , BM included intensified up-titration of medication by HF specialists in high-risk patients . NT-proBNP was used to define the level of risk and to monitor wall stress . This monitoring allowed for anticipation of cardiac decompensation and adjustment of medication in advance . RESULTS A total of 278 patients were r and omized in 8 Viennese hospitals . After 12 months , the BM group had the highest proportion of  antineurohormonal triple-therapy  ( difference among all groups ) . Accordingly , BM  reduced days of HF hospitalization ( 488 days ) compared with the hospitalization for the MC ( 1,254 days ) and UC ( 1,588 days ) groups ( p < 0.0001 ; significant differences among all groups ) . Using Kaplan-Meier analysis , the first HF rehospitalization ( 28 % ) was lower in the BM versus MC groups ( 40 % ; p = 0.06 ) and the MC versus UC groups ( 61 % ; p = 0.01 ) . Moreover , the combined end point of death or HF rehospitalization was lower in the BM ( 37 % ) than in the MC group ( 50 % ; p < 0.05 ) and in the MC than in the UC group ( 65 % ; p = 0.04 ) . Death rate was similar between the BM ( 22 % ) and MC groups ( 22 % ) , but was lower compared with the UC group ( 39 % ; vs. BM : p < 0.02 ; vs. MC : p < 0.02 ) . CONCLUSIONS Compared with MC alone , additional BM improves clinical outcome in patients after HF hospitalization . ( BNP Guided Care in Addition to Multidisciplinary Care ; NCT00355017 ) Background —Brain natriuretic peptide ( BNP ) and norepinephrine ( NE ) are strongly related to severity of and are independent predictors of outcome in heart failure . The long-term effects of angiotensin receptor blockers on BNP and NE in heart failure patients are not known . Methods and Results —Both BNP and NE were measured in 4284 patients r and omized to valsartan or placebo in the Valsartan Heart Failure Trial ( Val-HeFT ) at baseline and 4 , 12 , and 24 months after r and omization . The effects of valsartan were tested by ANCOVA , controlling for baseline values and concomitant ACE inhibitors and /or & bgr;-blockers  . BNP and NE concentrations were similar at baseline in the 2 groups and were decreased by valsartan starting at 4 months and up to 24 months . BNP increased over time in the placebo group . At the end point , least-squares mean ( ±SEM ) BNP increased from baseline by 23±5 pg/mL in the placebo group ( n=1979 ) but decreased by 21±5 pg/mL ( n=1940 ) in the valsartan group ( P < 0.0001 ) . NE increased by 41±6 pg/mL ( n=1979 ) and 12±6 pg/mL ( n=1941 ) for placebo and valsartan , respectively ( P = 0.0003 ) . Concomitant therapy with both ACE inhibitors and & bgr;-blockers significantly reduced the effect of valsartan on BNP but not on NE ( P for interaction=0.0223 and 0.2289 , respectively ) . Conclusions —In Val-HeFT , the largest neurohormone study in patients with symptomatic chronic heart failure , BNP and NE rose over time in the placebo group . Valsartan caused sustained reduction in BNP and attenuated the increase in NE over the course of the study . These neurohormone effects of valsartan are consistent with the clinical benefits reported in Val-HeFT BACKGROUND STARBRITE , a multicenter r and omized pilot trial , tested whether outpatient diuretic management guided by B-type natriuretic peptide ( BNP ) and clinical assessment result ed in more days alive and not hospitalized over 90 days compared with clinical assessment alone . METHODS AND RESULTS A total of 130 patients from 3 sites with left ventricular ejection fraction ≤35 % were enrolled during hospitalization for heart failure ( HF ) and r and omly assigned to therapy guided by BNP and clinical assessment ( BNP strategy ) or clinical assessment alone . The clinical goal was resolution of congestion without hypotension or renal dysfunction . In the BNP arm , therapy was adjusted to achieve optimal fluid status , defined as the BNP level and congestion score obtained at the time of discharge . In the clinical assessment arm , therapy was titrated to achieve optimal fluid status , represented by the patient 's signs and symptoms at the time of discharge . Exclusion criteria were serum creatinine > 3.5 mg/dL and acute coronary syndrome . Follow-up was done in HF clinics . BNP was measured with the use of a rapid assay test . There was no significant difference in number of days alive and not hospitalized ( hazard ratio 0.72 , 95 % confidence interval 0.41 - 1.27 ; P = .25 ) , change in serum creatinine , or change in systolic blood pressure ( SBP ) . BNP strategy was associated with a trend toward a lower blood urea nitrogen ( 24 mg/dL vs 29 mg/dL ; P = .07 ) ; BNP strategy patients received significantly more angiotensin-converting enzyme ( ACE ) inhibitors , beta-blockers , and the combination of ACE inhibitor or angiotensin receptor blocker plus beta-blockers . CONCLUSIONS BNP strategy was not associated with more days alive and not hospitalized , but the strategy appeared to be safe and was associated with increased use of evidence -based medications BACKGROUND Angiotensin-converting enzyme ( ACE ) inhibitors are established as first-line therapy in chronic heart failure ( CHF ) . However , conflicting results exist regarding the dose-effect relation of ACE inhibitors . METHODS We investigated 45 patients ( age 55 + /- 10 years ) with stable CHF who presented with a maintenance dosage of enalapril of either 5 mg given twice daily ( E10 ; n = 16 ) , 10 mg given twice daily ( E20 ; n = 18 ) , or 20 mg given twice daily ( E40 ; n = 11 ) . This dosage was changed 3 times to treat all patients with lower , higher , and the initial dosages for 4 weeks each . Neurohormones ( atrial natriuretic peptide [ ANP ] , brain natriuretic peptide [ BNP ] , and norepinephrine ) and enalaprilat trough levels were measured , and ergospirometry was performed . RESULTS Changes in enalapril dose and enalaprilat level were concordant in 82 % of patients , indicating good compliance . After augmentation of enalapril to 40 mg daily , patients in the E10 
    Output:
    
Furthermore , between-group BNP changes seemed to be a significant modifier to the effects of BNP-guided therapy on clinical outcomes , and BNP-guided therapy may improve the clinical outcomes of CHF patients if substantial reduction of BNP can be achieved .
In addition , BNP-guided therapy was not associated with increased risk for serious adverse events .
BNP-guided therapy may improve the clinical outcomes of CHF patients if substantial reduction of BNP can be achieved .