Abstract
Tremendous advances have been made in understanding the pathophysiology and treatment of congestive heart failure (CHF). However, diagnosis still remains difficult, even with a comprehensive physical examination. Symptoms such as dyspnea are non-specific and poorly sensitive indicators for early CHF that can be largely undetected. The discovery of natriuretic peptides (BNP) as diagnostic biomarkers has been one of the most critical advances for heart failure diagnosis. Therefore, both B-type and N-terminal pro-B-type have potential role in the diagnosis of heart failure, as well as in prognostic risk assessment. A single determination of BNP at any time during the progression of chronic HF provides a clinically useful tool for risk stratification. The hypothesis that repeated measurements might carry prognostic information beyond a single measure was confirmed in different settings. One of the main interests is given to the values of repeated determinations for monitoring progression of disease, and for the evaluation of the clinical effects of medical therapy. Nevertheless, despite thousands of papers describing their potential utility, current guidelines have not endorsed the highest level of recommendation for their use, in part, because the application in clinical practice is often limited for the absence of well codified cut off. Recently, European guidelines emphasized the role of natriuretic peptides as potential laboratory markers. In the near future, algorithm building will take into consideration clinical and echocardiographic parameters as well as NP measurements, and this may lead to a correct diagnosis and identification of patients at high risk. The purpose of this review is to discuss the clinical approaches and future applications of natriuretic peptides in heart failure and coronary disease.
Similar content being viewed by others
References
European Society of Cardiology, Heart Failure Association of the ESC (HFA), European Society of Intensive Care Medicine (ESICM), Dickstein K, Cohen-Solal A, Filippatos G, McMurray JJ, Ponikowski P, Poole-Wilson PA, Strömberg A, van Veldhuisen DJ, Atar D, Hoes AW, Keren A, Mebazaa A, Nieminen M, Priori SG, Swedberg K, Vahanian A, Camm J, De Caterina R, Dean V, Dickstein K, Filippatos G, Funck-Brentano C, Hellemans I, Kristensen SD, McGregor K, Sechtem U, Silber S, Tendera M, Widimsky P, Zamorano JL, Tendera M, Auricchio A, Bax J, Böhm M, Corrà U, della Bella P, Elliott PM, Follath F, Gheorghiade M, Hasin Y, Hernborg A, Jaarsma T, Komajda M, Kornowski R, Piepoli M, Prendergast B, Tavazzi L, Vachiery JL, Verheugt FW, Zamorano JL, Zannad F (2008) ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2008: the Task Force for the diagnosis and treatment of acute and chronic heart failure 2008 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association of the ESC (HFA) and endorsed by the European Society of Intensive Care Medicine (ESICM). Eur J Heart Fail 10(10):933–989
Fonarow GC, Peacock WF, Phillips CO, et al., ADHERE Scientific Advisory Committee and Investigators (2007) Admission B-type natriuretic peptide levels and in-hospital mortality in acute decompensated heart failure. J Am Coll Cardiol 49(19):1943–1950
Parrinello G, Torres D, Paterna S, Licata G (2009) Is there any novelty on the horizon of heart failure management in internal medicine? The evaluation of body fluid accumulation. Intern Emerg Med 4:269–270
Hirayama A, Kusuoka H, Yamamoto H, Sakata Y, Asakura M, Higuchi Y, Mizuno H, Kashiwase K, Ueda Y, Okuyama Y, Hori M, Kodama K (2005) Serial changes in plasma brain natriuretic peptide concentration at the infarct and non-infarct sites in patients with left ventricular remodelling after myocardial infarction. Heart 91(12):1573–1577
Silver MA, Maisel A, Yancy CW, McCullough PA, Burnett JC Jr, Francis GS, Mehra MR, Peacock WF 4th, Fonarow G, Gibler WB, Morrow DA, Hollander J, BNP Consensus Panel (2004) A clinical approach for the diagnostic, prognostic, screening, treatment monitoring, and therapeutic roles of natriuretic peptides in cardiovascular diseases. Congest Heart Fail 10(5 Suppl 3):1–30
De Lemos JA, McGuire DK, Khera A, Das SR, Murphy SA, Omland T, Drazner MH (2009) Screening the population for left ventricular hypertrophy and left ventricular systolic dysfunction using natriuretic peptides: results from the Dallas Heart Study. Am Heart J 157(4):746–753
Morrison LK, Harrison A, Krishnaswamy P, Kazanegra R, Clopton P, Maisel A (2002) Utility of a rapid B-natriuretic peptide assay in differentiating congestive heart failure from lung disease in patients presenting with dyspnea. J Am Coll Cardiol 16;39(2):202–209
Dentali F, Donadini M, Gianni M, Bertolini A, Lonn E, Venco A, Cattozzo G, Ageno W (2009) Brain natriuretic peptide as a preclinical marker of chronic pulmonary hypertension in patients with pulmonary embolism. Intern Emerg Med 4:123–128
Maisel AS, Krishnaswamy P, Nowak RM et al (2002) Rapid measurement of B-type natriuretic peptide in the emergency diagnosis of heart failure. N Engl J Med 347:161–167
Troughton RW, Prior DL, Pereira JJ, Martin M, Fogarty A, Morehead A, Yandle TG, Richards AM, Starling RC, Young JB, Thomas JD, Klein AL (2004) Plasma B-type natriuretic peptide levels in systolic heart failure: importance of left ventricular diastolic function and right ventricular systolic function. J Am Coll Cardiol 43:416–422
Troughton RW, Frampton CM, Yandle TG, Espiner EA, Nicholls MG, Richards AM (2001) Treatment of heart failure guided by plasma aminoterminal brain natriuretic peptide (N-BNP) concentrations. Lancet 355(9210):1126–1130
Tschope C, Kasner M, Westermann D, Gaub R, Poller WC, Schultheiss HP (2005) The role of NT-proBNP in the diagnostics of isolated diastolic dysfunction: correlation with echocardiographic and invasive measurements. Eur Heart J 26:2277–2284
Dong SJ, de las Fuentes L, Brown AL, Waggoner AD, Ewald GA, Davila-Roman VG (2006) N-terminal pro B-type natriuretic peptide levels: correlation with echocardiographically determined left ventricular diastolic function in an ambulatory cohort. J Am Soc Echocardiogr 19:1017–1025
Lim TK, Ashrafian H, Dwivedi G, Collinson PO, Senior R (2006) Increased left atrial volume index is an independent predictor of raised serum natriuretic peptide in patients with suspected heart failure but normal left ventricular ejection fraction: implication for diagnosis of diastolic heart failure. Eur J Heart Fail 8:38–45
Kirk V, Bay M, Parner J, Krogsgaard K, Herzog TM, Boesgaard S, Hassager C, Nielsen OW, Aldershvile J, Nielsen H (2004) N-terminal proBNP and mortality in hospitalised patients with heart failure and preserved vs. reduced systolic function: data from the prospective Copenhagen Hospital Heart Failure Study (CHHF). Eur J Heart Fail 6:335–341
Antman EM, Cohen M, Bernink PJ, McCabe CH, Horacek T, Papuchis G et al (2000) The TIMI risk score for unstable angina/non ST elevation MI: a method for prognostication and therapeutic decision making. JAMA 284:835–842
Palazzuoli A, Gennari L, Calabria P, Quatrini I, Vecchiato L, De Paola V et al (2005) Relation of plasma brain natriuretic peptide levels in non-ST-elevation coronary disease and preserved systolic function to number of narrowed coronary arteries. Am J Cardiol 96:1705–1710
Morrow DA, Braunwald E (2003) Future of biomarkers in acute coronary syndromes moving toward multimarker strategy. Circulation 108:250–252
Ezekowitz JA, Théroux P, Chang W, Mahaffey KW, Granger CB, Weaver WD, Hochman JS, Armstrong PW (2006) N-terminal pro-brain natriuretic peptide and the timing, extent and mortality in ST elevation myocardial infarction. Can J Cardiol 22:393–397
Harrison A, Morrison LK, Krishnaswamy P, Kazanegra R, Clopton P, Dao Q, Hlavin P, Maisel A (2002) B-type natriuretic peptide predicts future cardiac events in patients presenting to the emergency department with dyspnea. Ann Emerg Med 39:131–138
Bettencourt P, Azevedo A, Pimenta J, Friões F, Ferreira S, Ferreira A (2004) N-terminal-pro-brain natriuretic peptide predicts outcome after hospital discharge in heart failure patients. Circulation 110:2168–2174
Aspromonte N, Valle R, Peacock WF, Vanderheyden M, Maisel A (2008) Inpatient monitoring and prognostic importance of B-type natriuretic peptide. Congest heart Fail 14:30–34
Donadini MP, Squizzato A, Dentali F, Ageno W (2009) Prognostic stratification of chronic heart failure in elderly population: are cardiopulmonary tests and BNP really valuable? Intern Emerg Med 4:123–128
Palazzuoli A, Deckers J, Calabrò A, Campagna MS, Nuti R, Pastorelli M, Pasqui AL, Bruni F, Auteri A, Puccetti L (2006) Brain natriuretic peptide and other risk markers for outcome assessment in patients with non-ST-elevation coronary syndromes and preserved systolic function. Am J Card 98:1322–1328
Richards AM, Doughty R, Nicholls MG, MacMahon S, Sharpe N, Murphy J, Espiner EA, Frampton C, Yandle TG, Australia–New Zealand Heart Failure Group (2006) Plasma N-terminal pro-brain natriuretic peptide and adrenomedullin: prognostic utility and prediction of benefit from carvedilol in chronic ischemic left ventricular dysfunction. J Am Coll Cardiol 37:1781–1787
Cohn N, Tognoni G (2001) A randomized trial of the angiotensin-receptor blocker valsartan in chronic heart failure. N Engl J Med 345:1667–1675
Masson S, Latini R, Anand IS, Vago T, Angelici L, Barlera S, Missov ED, Clerico A, Tognoni G, Cohn JN (2006) Direct comparison of B-type natriuretic peptide (BNP) and amino-terminal proBNP in a large population of patients with chronic and symptomatic heart failure: the Valsartan Heart Failure (Val-HeFT) data. Clin Chem 52:1528–1538
Dieplinger B, Gegenhuber A, Haltmayer M, Mueller T (2009) Evaluation of novel biomarkers for the diagnosis of acute destabilized heart failure in shortness-of-breath patients. Heart 95(18):1508–1513
Voors AA, von Haehling S, Anker SD et al (2009) C-terminal provasopressin (copeptin) is a strong prognostic marker in patients with heart failure after an acute myocardial infarction: results from the OPTIMAAL study. Eur Heart J 30:1187–1194
Conflict of interest
None.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Palazzuoli, A., Antonelli, G., Quatrini, I. et al. Natriuretic peptides in heart failure: where we are, where we are going. Intern Emerg Med 6, 63–68 (2011). https://doi.org/10.1007/s11739-010-0438-x
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11739-010-0438-x