Metal-like Charge Transport in PEDOT(OH) Films by Post-processing Side Chain Removal from a Soluble Precursor Polymer.

Herein, a route to produce highly electrically conductive doped hydroxymethyl functionalized poly(3,4-ethylenedioxythiophene) (PEDOT) films, termed PEDOT(OH) with metal-like charge transport properties using a fully solution processable precursor polymer is reported. This is achieved via an ester-functionalized PEDOT derivative [PEDOT(EHE)] that is soluble in a range of solvents with excellent film-forming ability. PEDOT(EHE) demonstrates moderate electrical conductivities of 20-60 S cm-1 and hopping-like (i.e., thermally activated) transport when doped with ferric tosylate (FeTos3 ). Upon basic hydrolysis of PEDOT(EHE) films, the electrically insulative side chains are cleaved and washed from the polymer film, leaving a densified film of PEDOT(OH). These films, when optimally doped, reach electrical conductivities of ≈1200 S cm-1 and demonstrate metal-like (i.e., thermally deactivated and band-like) transport properties and high stability at comparable doping levels.

Significant Enhancement of the Electrical Conductivity of Conjugated Polymers by Post-Processing Side Chain Removal.

The processability and electronic properties of conjugated polymers (CPs) have become increasingly important due to the potential of these materials in redox and solid-state devices for a broad range of applications. To solubilize CPs, side chains are needed, but such side chains reduce the relative fraction of electroactive material in the film, potentially obstructing π-π intermolecular interactions, localizing charge carriers, and compromising desirable optoelectronic properties. To reduce the deleterious effects of side chains, we demonstrate that post-processing side chain removal, exemplified here via ester hydrolysis, significantly increases the electrical conductivity of chemically doped CP films. Beginning with a model system consisting of an ester functionalized ProDOT copolymerized with a dimethylProDOT, we used a variety of methods to assess the changes in polymer film volume and morphology upon hydrolysis and resulting active material densification. Via a combination of electrochemistry, X-ray photoelectron spectroscopy, and charge transport models, we demonstrate that this increase in electrical conductivity is not due to an increase in degree of doping but an increase in charge carrier density and reduction in carrier localization that occurs due to side chain removal. With this improved understanding of side chain hydrolysis, we then apply this method to high-performance ProDOT-alt-EDOTx copolymers. After hydrolysis, these ProDOT-alt-EDOTx copolymers yield exceptional electrical conductivities (∼700 S/cm), outperforming all previously reported oligoether-/glycol-based CP systems. Ultimately, this methodology advances the ability to solution process highly electrically conductive CP films.

Quantifying charge carrier localization in chemically doped semiconducting polymers.

Charge transport in semiconducting polymers ranges from localized (hopping-like) to delocalized (metal-like), yet no quantitative model exists to fully capture this transport spectrum and its dependency on charge carrier density. In this study, using an archetypal polymer-dopant system, we measure the temperature-dependent electrical conductivity, Seebeck coefficient and extent of oxidation. We then use these measurements to develop a semi-localized transport (SLoT) model, which captures both localized and delocalized transport contributions. By applying the SLoT model to published data, we demonstrate its broad utility. We are able to determine system-dependent parameters such as the maximum localization energy of the system, how this localization energy changes with doping, the amount of dopant required to achieve metal-like conductivity and the conductivity a system could have in the absence of localization effects. This proposed SLoT model improves our ability to predict and tailor electronic properties of doped semiconducting polymers.

Single-Cycle Atomic Layer Deposition on Bulk Wood Lumber for Managing Moisture Content, Mold Growth, and Thermal Conductivity.

Wood is a universal building material. While highly versatile, many of its critical properties vary with water content (e.g., dimensionality, mechanical strength, and thermal insulation). Treatments to control the water content in wood have many technological applications. This study investigates the use of single-cycle atomic layer deposition (1cy-ALD) to apply <1 nm Al2O3, ZnO, or TiO2 coatings to various bulk lumber species (pine, cedar, and poplar) to alter their wettability, fungicidal, and thermal transport properties. Because the 1cy-ALD process only requires a single exposure to the precursors, it is potentially scalable for commodity product manufacturing. While all ALD chemistries are found to make the wood's surface hydrophobic, wood treated with TiO2 (TiCl4 + H2O) shows the greatest bulk water repellency upon full immersion in water. In situ monitoring of the chamber reaction pressure suggests that the TiCl4 + H2O chemistry follows reaction-rate-limited processing kinetics that enables deeper diffusion of the precursors into the wood's fibrous structure. Consequently, in humid or moist environments, 1cy-ALD (TiCl4 + H2O) treated lumber shows a 4 times smaller increase in thermal conductivity and improved resistance to mold growth compared to untreated lumber.

Vapor Phase Infiltration of Titanium Oxide into P3HT to Create Organic-Inorganic Hybrid Photocatalysts.

Herein, we report for the first time the use of vapor phase infiltration (VPI) to infuse conducting polymers with inorganic metal oxide clusters that together form a photocatalytic material. While vapor infiltration has previously been used to electrically dope conjugated polymers, this is the first time, to our knowledge, that the resultant hybrid material has been demonstrated to have photocatalytic properties. The system studied is poly(3-hexylthiophene-2,5-diyl) (P3HT) vapor infiltrated with TiCl4 and H2O to create P3HT-TiOx organic-inorganic hybrid photocatalytic materials. X-ray photoelectron spectroscopy analysis shows that P3HT-TiOx VPI films consist of a partially oxidized P3HT matrix, and the infiltrated titanium inorganic is in a 4+ oxidation state with mostly oxide coordination. Upon visible light illumination, these P3HT-TiOx hybrids degrade methylene blue dye molecules. The P3HT-TiOx hybrids are 4.6× more photocatalytically active than either the P3HT or TiO2 individually or when sequentially deposited (e.g., P3HT on TiO2). On a per surface area basis, these hybrid photocatalysts are comparable or better than other best in class polymer semiconductor photocatalysts. VPI of TiCl4 + H2O into P3HT makes a unique hybrid structure and idealized photocatalyst architecture by creating nanoscale TiOx clusters concentrated toward the surface achieving extremely high catalytic rates. The mechanism for this enhanced photocatalytic rate is understood using photoluminescence spectroscopy, which shows significant quenching of excitons in P3HT-TiOx as compared to neat P3HT, indicating that P3HT acts as a photosensitizer for the TiOx catalyst sites in the hybrid material. This work introduces a new approach to designing and synthesizing organic-inorganic hybrid photocatalytic materials, with expansive opportunities for further exploration and optimization.

Quantifying Charge Carrier Localization in PBTTT Using Thermoelectric and Spectroscopic Techniques.

Chemically doped poly[2,5-bis(3-alkylthiophen-2-yl)thieno[3,2-b]thiophene] (PBTTT) shows promise for many organic electronic applications, but rationalizing its charge transport properties is challenging because conjugated polymers are inhomogeneous, with convoluted optical and solid-state transport properties. Herein, we use the semilocalized transport (SLoT) model to quantify how the charge transport properties of PBTTT change as a function of iron(III) chloride (FeCl3) doping level. We use the SLoT model to calculate fundamental transport parameters, including the carrier density needed for metal-like electrical conductivities and the position of the Fermi energy level with respect to the transport edge. We then contextualize these parameters with other polymer-dopant systems and previous PBTTT reports. Additionally, we use grazing incidence wide-angle X-ray scattering and spectroscopic ellipsometry techniques to better characterize inhomogeneity in PBTTT. Our analyses indicate that PBTTT obtains high electrical conductivities due to its quickly rising reduced Fermi energy level, and this rise is afforded by its locally high carrier densities in highly ordered microdomains. Ultimately, this report sets a benchmark for comparing transport properties across polymer-dopant-processing systems.

Effects of film thickness on electrochemical properties of nanoscale polyethylenedioxythiophene (PEDOT) thin films grown by oxidative molecular layer deposition (oMLD).

Poly(3,4-ethylene dioxythiophene) (PEDOT) has a high theoretical charge storage capacity, making it of interest for electrochemical applications including energy storage and water desalination. Nanoscale thin films of PEDOT are particularly attractive for these applications to enable faster charging. Recent work has demonstrated that nanoscale thin films of PEDOT can be formed using sequential gas-phase exposures via oxidative molecular layer deposition, or oMLD, which provides advantages in conformality and uniformity on high aspect ratio substrates over other deposition techniques. But to date, the electrochemical properties of these oMLD PEDOT thin films have not been well-characterized. In this work, we examine the electrochemical properties of 5-100 nm thick PEDOT films formed using 20-175 oMLD deposition cycles. We find that film thickness of oMLD PEDOT films affects the orientation of ordered domains leading to a substantial change in charge storage capacity. Interestingly, we observe a minimum in charge storage capacity for an oMLD PEDOT film thickness of ∼30 nm (60 oMLD cycles at 150 °C), coinciding with the highest degree of face-on oriented PEDOT domains as measured using grazing incidence wide angle X-ray scattering (GIWAXS). Thinner and thicker oMLD PEDOT films exhibit higher fractions of oblique (off-angle) orientations and corresponding increases in charge capacity of up to 120 mA h g-1. Electrochemical measurements suggest that higher charge capacity in films with mixed domain orientation arise from the facile transport of ions from the liquid electrolyte into the PEDOT layer. Greater exposure of the electrolyte to PEDOT domain edges is posited to facilitate faster ion transport in these mixed domain films. These insights will inform future design of PEDOT coated high-aspect ratio structures for electrochemical energy storage and water treatment.

Elucidating Design Rules toward Enhanced Solid-State Charge Transport in Oligoether-Functionalized Dioxythiophene-Based Alternating Copolymers.

This study investigates the solid-state charge transport properties of the oxidized forms of dioxythiophene-based alternating copolymers consisting of an oligoether-functionalized 3,4-propylenedioxythiophene (ProDOT) copolymerized with different aryl groups, dimethyl ProDOT (DMP), 3,4-ethylenedioxythiophene (EDOT), and 3,4-phenylenedioxythiophene (PheDOT), respectively, to yield copolymers P(OE3)-D, P(OE3)-E, and P(OE3)-Ph. At a dopant concentration of 5 mM FeTos3, the electrical conductivities of these copolymers vary significantly (ranging between 9 and 195 S cm-1) with the EDOT copolymer, P(OE3)-E, achieving the highest electrical conductivity. UV-vis-NIR and X-ray spectroscopies show differences in both susceptibility to oxidative doping and extent of oxidation for the P(OE3) series, with P(OE3)-E being the most doped. Wide-angle X-ray scattering measurements indicate that P(OE3)-E generally demonstrates the lowest paracrystallinity values in the series, as well as relatively small π-π stacking distances. The significant (i.e., order of magnitude) increase in electrical conductivity of doped P(OE3)-E films versus doped P(OE3)-D or P(OE3)-Ph films can therefore be attributed to P(OE3)-E exhibiting both the highest carrier ratios in the P(OE3) series, along with good π-π overlap and local ordering (low paracrystallinity values). Furthermore, these trends in the extent of doping and paracrystallinity are consistent with the reduced Fermi energy level and transport function prefactor parameters calculated using the semilocalized transport (SLoT) model. Observed differences in carrier ratios at the transport edge (ct) and reduced Fermi energies [η(c)] suggest a broader electronic band (better overlap and more delocalization) for the EDOT-incorporating P(OE3)-E polymer relative to P(OE3)-D and P(OE3)-Ph. Ultimately, we rationalize improvements in electrical conductivity due to microstructural and doping enhancements caused by EDOT incorporation, a structure-property relationship worth considering in the future design of highly electrically conductive systems.

Heart failure outcomes and benefits of NT-proBNP-guided management in the elderly: results from the prospective, randomized ProBNP outpatient tailored chronic heart failure therapy (PROTECT) study.

BACKGROUND: Elderly patients with heart failure (HF) have a worse prognosis than younger patients. We wished to study whether elders benefit from natriuretic peptide-guided HF care in this single-center study. METHODS AND RESULTS: A total of 151 patients with HF resulting from left ventricular systolic dysfunction (LVSD) were treated with HF treatment by standard-of-care (SOC) management or guided by N-terminal pro-B type natriuretic peptide (NT-proBNP) values (with a goal to lower NT-proBNP ≤1000 pg/mL) over 10 months. The primary end point for this post-hoc analysis was total cardiovascular events in 2 age categories (<75 and ≥75 years). In those ≥75 years of age (n = 38), NT-proBNP values increased in the SOC arm (2570 to 3523 pg/mL, P = .01), but decreased in the NT-proBNP-guided arm (2664 to 1418 pg/mL, P = .001). Elderly patients treated with SOC management had the highest rate of cardiovascular events, whereas the elderly with NT-proBNP management had the lowest rate of cardiovascular events (1.76 events per patient versus 0.71 events per patient, P = .03); the adjusted logistic odds for cardiovascular events related to NT-proBNP-guided care for elders was 0.24 (P = .008), whereas in those <75 years (n = 113), the adjusted logistic odds for events following NT-proBNP-guided care was 0.61 (P = .10). CONCLUSIONS: Natriuretic peptide-guided HF care was well tolerated and resulted in substantial improvement in cardiovascular event rates in elders (ClinicalTrials.Gov #00351390).

Iron(III) Dopant Counterions Affect the Charge-Transport Properties of Poly(Thiophene) and Poly(Dialkoxythiophene) Derivatives.

This study investigates the charge-transport properties of poly(3-hexylthiophene-2,5-diyl) (P3HT) and poly(ProDOT-alt-biEDOT) (PE2) films doped with a set of iron(III)-based dopants and as a function of dopant concentration. X-ray photoelectron spectroscopy measurements show that doping P3HT with 12 mM iron(III) solutions leads to similar extents of oxidation, independent of the dopant anion; however, the electrical conductivities and Seebeck coefficients vary significantly (5 S cm-1 and + 82 µV K-1 with tosylate and 56 S cm-1 and +31 µV K-1 with perchlorate). In contrast, PE2 thermoelectric transport properties vary less with respect to the iron(III) anion chemistry, which is attributed to PE2 having a lower onset of oxidation than P3HT. Consequentially, PE2 doped with 12 mM iron(III) perchlorate obtained an electrical conductivity of 315 S cm-1 and a Seebeck coefficient of + 7 µV K-1. Modeling these thermoelectric properties with the semilocalized transport (SLoT) model suggests that tosylate-doped P3HT remains mostly in the localized transport regime, attributed to more disorder in the microstructure. In contrast perchlorate-doped P3HT and PE2 films exhibited thermally deactivated electrical conductivities and metal-like transport at high doping levels over limited temperature ranges. Finally, the SLoT model suggests that PE2 has the potential to be more electrically conductive than P3HT due to PE2's ability to achieve higher extents of oxidation and larger shifts in the reduced Fermi energy levels.

Pulsed heating atomic layer deposition (PH-ALD) for epitaxial growth of zinc oxide thin films on c-plane sapphire.

An in situ pulsed heating atomic layer deposition (PH-ALD) technique is used to grow heteroepitaxial ZnO thin films on c-plane sapphire with temperature-sensitive metalorganic precursors. During metalorganic precursor delivery, the substrate is maintained at a base temperature of 110 °C to prevent thermal decomposition of the precursors. After the substrate is sequentially exposed to the metalorganic precursor and water co-reactant at this low temperature, a high-power resistive heater is used to rapidly heat the substrate to between 400 and 900 °C to drive film crystallization. These in situ heat pulses enable epitaxial growth of (0001) ZnO films on c-plane sapphire. Rocking curves with FWHM of values as low as 0.53° are achieved. In contrast, films deposited entirely at 110 °C appear random polycrystalline and post-deposition annealing to 900 °C achieves only partial "epitaxial character" with a notably different in-plane orientation. Variations in heat pulse temperature and the number of deposition cycles between heat pulses are explored. Epitaxial growth persists up to 5 deposition cycles per heat pulse, with the 2θ-ω FWHM increasing to 1-2°. To further reduce process times, a templating approach is also explored in which a limited number of "template" layers are initially deposited with PH-ALD followed by low-temperature ALD at 110 °C. Epitaxial growth is encouraged with as few as 5 cycles of PH-ALD followed by 495 cycles of low-temperature ALD. Crystal quality further improves by using up to 50 template cycles, with a 2θ-ω FWHM of 1.3°. Epilayers also show enhanced photoluminescence (PL) at room temperature. These results demonstrate how in situ pulse-heating can be used to promote epitaxial film growth in ALD processes using temperature-sensitive metalorganic precursors.

Delayed heart rate recovery after adenosine stress testing with supplemental arm exercise predicts mortality.

BACKGROUND: Delayed heart rate (HR) recovery after treadmill exercise testing predicts mortality. Patients with suspected ischemic heart disease who cannot perform adequate treadmill exercise are typically evaluated with pharmacological stress myocardial perfusion imaging (MPI) studies, but little prognostic significance has been attributed to the hemodynamic response to vasodilator stress testing with low-level exercise. We hypothesized that a delay in HR recovery after adenosine stress testing with arm exercise is associated with increased mortality. METHODS AND RESULTS: Technetium 99m-Sestamibi MPI was performed in 1,455 consecutive patients (70 +/- 12 years, 50.2% men) with adenosine stress and supplemental arm exercise. HRs were recorded at rest, continuously during infusion, and then 5 minutes post-infusion. Delayed HR recovery was defined as a decline of < or = 12 bpm from peak HR at 5 minutes after discontinuation of the infusion. Of 1,356 patients during 5 years of follow up, there were 135 deaths (10%). Delayed HR recovery was strongly predictive of all-cause mortality (16.5% vs 5.3% in those with normal HR recovery, P < .001) with an adjusted hazard ratio of 2.5 (95% CI, 1.7-3.6; P < .001). CONCLUSION: Delayed HR recovery after adenosine stress testing with arm exercise is a readily available and powerful predictor of all-cause mortality.

Clinical uncertainty, diagnostic accuracy, and outcomes in emergency department patients presenting with dyspnea.

BACKGROUND: Dyspnea is a common complaint in the emergency department (ED) and may be a diagnostic challenge. We hypothesized that diagnostic uncertainty in this setting is associated with adverse outcomes, and amino-terminal pro-B-type natriuretic peptide (NT-proBNP) testing would improve diagnostic accuracy and reduce diagnostic uncertainty. METHODS: A total of 592 dyspneic patients were evaluated from the ProBNP Investigation of Dyspnea in the Emergency Department (PRIDE) study. Managing physicians were asked to provide estimates from 0% to 100%of the likelihood of acutely destabilized heart failure (ADHF). A certainty estimate of either 20% or lower or 80% or higher was classified as clinical certainty, while estimates between 21% and 79% were defined as clinical uncertainty. Associations between clinical uncertainty,hospital length of stay, morbidity, and mortality were examined. The diagnostic value of clinical judgment vs NT-proBNP measurement was compared across categories of clinical certainty. RESULTS: Clinical uncertainty was present in 185 patients (31%), 103 (56%) of whom had ADHF. Patients judged with clinical uncertainty had longer hospital length of stay and increased morbidity and mortality,especially those with ADHF. Receiver operating characteristic analysis of clinical judgment yielded an area under the curve (AUC) of 0.88 in the clinical certainty group and 0.76 in the uncertainty group (P<.001); NT-proBNP testing alone in these same groups had AUCs of 0.96 and 0.91, respectively. The combination of clinical judgment with NT-proBNP testing yielded improvements in AUC. CONCLUSIONS: Among dyspneic patients in the ED, clinical uncertainty is associated with increased morbidity and mortality, especially in those with ADHF.The addition of NT-proBNP testing to clinical judgment may reduce diagnostic uncertainty in this setting.

Myocardial blood flow and oxygen consumption in patients with Friedreich's ataxia prior to the onset of cardiomyopathy.

OBJECTIVES: We tested the hypothesis, in patients with Friedreich's ataxia and no overt structural heart disease, that impairment of cardiac oxidative metabolism may be compensated for either by increased rest myocardial blood flow or more efficient oxygen consumption in performance of external work. BACKGROUND: Friedreich's ataxia is characterized by a mutant frataxin gene, which causes mitochondrial iron overload and impaired energy production. Further, it is frequently associated with cardiomyopathy. Studies using magnetic resonance spectroscopy, however, suggest impaired cardiac energetics even in the absence of structural heart disease. METHODS: Positron emission tomography measured rest myocardial blood flow (N-13-ammonia method) and myocardial oxygen consumption (11-C-acetate, Kmono) in Friedreich's ataxia patients (n=8; 31+/-5 years, mean+/-SD, four women) and healthy controls (n=8; 30+/-7 years, five women) matched for stroke work index and age. Stroke work index and power were determined by electrocardiogram gated positron emission tomography N-13-ammonia using modified Simpson's rule to compute left ventricular volumes. RESULTS: Neither stroke work index nor rest myocardial blood flow differed significantly between the groups. Although myocardial oxygen consumption was lower in Friedreich's ataxia (P<0.001), Kmono/rest myocardial blood flow, an index of myocardial oxygen extraction, did not differ between the groups. Power/Kmono, an index of the efficiency of myocardial oxygen consumption, was greater in Friedreich's ataxia (P<0.04). Rest myocardial blood flow normalized to rate pressure product was lower in Friedreich's ataxia (P<0.05). CONCLUSIONS: Prior to the onset of cardiomyopathy, selected patients with Friedreich's ataxia may compensate for impaired cardiac energetics through more efficient oxygen consumption rather than increased rest myocardial blood flow. The data illustrate a more general mechanism pertaining to metabolic regulation of myocardial blood flow and myocardial oxygen consumption.

Comparison of sixty-four-slice multidetector computed tomographic coronary angiography to coronary angiography with intravascular ultrasound for the detection of transplant vasculopathy.

Coronary allograft vasculopathy (CAV) is the most important limitation to long-term survival in adult heart transplant recipients and is difficult to detect without intravascular ultrasound (IVUS). We systematically evaluated the image quality of 64-slice multidetector computed tomographic (MDCT) coronary angiography in heart transplant recipients and tested the hypothesis that this modality is comparable to invasive coronary angiography with IVUS for the detection of CAV. Heart transplant recipients (n = 20) underwent invasive coronary angiography with IVUS and MDCT coronary angiography with a 64-slice scanner. Images were systematically analyzed for image quality and the presence of CAV. In addition, multidetector computed tomography and quantitative coronary angiography were used to measure lumen diameters at prespecified locations. Image quality analysis showed that, despite high mean heart rates (77 +/- 7 beats/min) and body mass index (29.5 +/- 5.3 kg/m(2)), 83% of coronary segments were graded as of excellent or good image quality. On average, 95 +/- 9% of the overall visualized length of the coronary arteries was imaged without motion artifacts, and the mean contrast-to-noise ratio was 11.3 +/- 4.6. Compared with IVUS, multidetector computed tomography had a sensitivity of 70%, specificity of 92%, positive predictive value of 89%, and negative predictive value of 77% for the detection of CAV. MDCT vessel diameter measurements correlated well with those obtained from quantitative coronary angiography (R(2) = 0.89). In conclusion, 64-slice multidetector computed tomography provides good to excellent image quality in heart transplant recipients and has moderate to excellent test characteristics for the detection of CAV. Further, MDCT measurements of lumen diameters correlated well with quantitative coronary angiography.

The Prognostic Significance of Resting Regional Left Ventricular Function in Patients With Varying Degrees of Myocardial Ischemia.

BACKGROUND: Our aim was to determine whether regional left ventricular (LV) function on a resting transthoracic echo (TTE) provides prognostic information in patients with varying degrees of ischemia on myocardial perfusion imaging. METHODS: Between 2004 - 2009, we identified 503 patients (mean age 69 (SD 11); 79% male) with reversible ischemia on a myocardial SPECT scan who had a TTE within 30 days. We evaluated the rate of subsequent revascularization and death for all patients. RESULTS: Following the SPECT scan and TTE, 246/503(49%) patients underwent revascularization, 64/503 (13%) patients died, 369 (73%) patients had a normal left ventricular ejection fraction (LVEF), 242 (48%) patients had a resting wall motion abnormality (WMA), 21/261 (8%) with no WMA died compared to 43/242 (18%) in patients with a WMA. In patients with a WMA (n = 242) there was no significant difference in mortality when comparing patients with small (< 6 segments) and large (> 6 segments) WMA (P = 0.44). In patients with moderate/severe ischemia, the presence of a resting WMA was associated with a higher mortality rate (18% v 7%; P = 0.005). In a multivariable model, LVEF (< 50%) was associated with a hazard ratio of 2.2 (P = 0.002, 95% CI 1.34 - 3.68) however, WMA and number of abnormal segments did not reach statistical significance. CONCLUSION: A resting wall motion abnormality in patients with moderate/severe ischemia is associated with a higher mortality compared to patients with mild ischemia on myocardial perfusion imaging. Regional left ventricular dysfunction unlike LVEF was not an independent predictor of mortality.

Improvement in structural and functional echocardiographic parameters during chronic heart failure therapy guided by natriuretic peptides: mechanistic insights from the ProBNP Outpatient Tailored Chronic Heart Failure (PROTECT) study.

AIMS: We sought to determine if heart failure (HF) care with a goal to lower N-terminal pro B-type natriuretic peptide (NT-proBNP) concentrations, compared with standard of care (SOC) management, is associated with improvement in echocardiographic parameters of cardiac structure and function. METHODS AND RESULTS: Of 151 subjects with HF due to left ventricular systolic dysfunction (LVSD) prospectively randomized to NT-proBNP-guided vs. SOC HF care, 116 had serial echocardiographic data. Endpoints in this echocardiographic study included the relationship between change in NT-proBNP and LV reverse remodelling, as well as associations between biomarker-guided therapy and measures of diastolic function, right ventricular (RV) size and function, estimates of LV filling pressure and RV systolic pressure (RVSP), and the degree of mitral regurgitation (MR). After a mean of 10 months of study procedures, in adjusted analyses, final NT-proBNP concentrations predicted risk of remodelling [hazard ratio (HR) ↑LV end-diastolic volume index = 1.43, 95% confidence interval (CI) 1.10-1.86, P = 0.007; HR ↑LV end-systolic volume index = 1.54, 95% CI 1.10-1.91, P = 0.01; HR ↓LV ejection fraction (LVEF) = 1.53, 905% CI 1.12-1.89, P = 0.02]. In addition to greater improvement in LVEF and reductions in LV volume, compared with SOC, NT-proBNP-guided patients showed significant decreases in the ratio of early transmitral peak velocity to early diastolic peak annular velocity (E/E'), pulmonary vein peak S velocity, RV fractional area change, RVSP, and MR severity. CONCLUSION: NT-proBNP concentrations may serve as a non-invasive indicator of the state of cardiac structure and function in HF due to LVSD. Multiple, prognostically meaningful echocardiographic variables improved more significantly in patients treated with NT-proBNP-guided care vs. SOC.

Use of amino-terminal pro-B-type natriuretic peptide to guide outpatient therapy of patients with chronic left ventricular systolic dysfunction.

OBJECTIVES: The aim of this study was to evaluate whether chronic heart failure (HF) therapy guided by concentrations of amino-terminal pro-B-type natriuretic peptide (NT-proBNP) is superior to standard of care (SOC) management. BACKGROUND: It is unclear whether standard HF treatment plus a goal of reducing NT-proBNP concentrations improves outcomes compared with standard management alone. METHODS: In a prospective single-center trial, 151 subjects with HF due to left ventricular (LV) systolic dysfunction were randomized to receive either standard HF care plus a goal to reduce NT-proBNP concentrations ≤1,000 pg/ml or SOC management. The primary endpoint was total cardiovascular events between groups compared using generalized estimating equations. Secondary endpoints included effects of NT-proBNP-guided care on patient quality of life as well as cardiac structure and function, assessed with echocardiography. RESULTS: Through a mean follow-up period of 10 ± 3 months, a significant reduction in the primary endpoint of total cardiovascular events was seen in the NT-proBNP arm compared with SOC (58 events vs. 100 events, p = 0.009; logistic odds for events 0.44, p = 0.02); Kaplan-Meier curves demonstrated significant differences in time to first event, favoring NT-proBNP-guided care (p = 0.03). No age interaction was found, with elderly patients benefitting similarly from NT-proBNP-guided care as younger subjects. Compared with SOC, NT-proBNP-guided patients had greater improvements in quality of life, demonstrated greater relative improvements in LV ejection fraction, and had more significant improvements in both LV end-systolic and -diastolic volume indexes. CONCLUSIONS: In patients with HF due to LV systolic dysfunction, NT-proBNP-guided therapy was superior to SOC, with reduced event rates, improved quality of life, and favorable effects on cardiac remodeling. (Use of NT-proBNP Testing to Guide Heart Failure Therapy in the Outpatient Setting; NCT00351390).