BNP-Guided Heart Failure Therapy in Older Patients—Reply

In Reply: We agree with Dr Bhaskar that patients with heart failure should not be denied proven therapy based on symptoms even in presence of concomitant COPD. Thus, in TIME-CHF 313 of 322 patients (97%) without COPD and 78 of 83 (94%) with COPD were prescribed β-blockers after 6 months (P = .18) without differences in dosage. However, patients with severe COPD were excluded from the trial. To ensure that dyspnea at inclusion was in fact due to heart failure, a history of heart failure within the last year was required in all patients. BNP values at baseline were used to identify patients with cardiac reasons for dyspnea, not to further distinguish causes of heart failure, particularly right heart failure or COPD. In subgroup analyses, there was no interaction of COPD with the 2 treatment strategies relative to outcome (eg, P = .32 for the primary end point). But the point raised by Bhaskar may still be valid, particularly in patients with severe COPD not studied in TIME-CHF. We hope the ongoing analysis of all echocardiograms in our study will provide more insights into the interrelation between right ventricular function, pulmonary artery pressures, and BNP.