The potential role of natriuretic peptides and other biomarkers in heart failure diagnosis, prognosis and management

Abstract

Heart failure (HF) is a complex disease process that is challenging to diagnose and manage. For more than 15 years, biomarkers have been used to diagnose and the guide the management of patients with this disease. The gold standard biomarkers for HF are B-type natriuretic peptide (BNP) and N-terminal proBNP (NT-proBNP); both are used for diagnosis and prognosis. More recently, there has been an interest in use of BNP and NT-proBNP for HF management as well. Important aspects regarding production and clearance of BNP and NT-proBNP exist, which are vital for the clinician to understand. Beyond BNP or NT-proBNP, other newer biomarkers such as mid-regional pro-atrial natriuretic peptide, soluble ST2, highly sensitive troponin and renal biomarkers may add value for prognostication and possibly, patient management. In this article, the authors will discuss the established and evolving role of BNP and NT-proBNP in HF, along with consideration of select newer biomarkers in this setting.

Keywords:

• biomarkers
• heart failure
• natriuretic peptides

Financial & competing interests disclosure

JL Januzzi has received grant support from Singulex, Thermo-Fisher, Siemens and Prevencio and has received consulting income from Roche Diagnostics, Critical Diagnostics, Sphingotec, diaDexus and Novartis. JL Januzzi has also received payment for service on clinical end point adjudication committees and/or data safety monitoring boards for Novartis, Amgen, Janssen and Boeringer-Ingelheim. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Key issues

• Heart failure (HF) is a complex disease that can be difficult to diagnose and manage. As such, biomarkers may be added to traditional history and physical examination to improve diagnostic and prognostic accuracy, and assist in management.

• The gold standard biomarkers for the diagnosis and management of HF are the natriuretic peptides: B-type natriuretic peptide (BNP) and N-terminal proBNP.

• Many factors affect the levels of the BNP and N-terminal proBNP and these include age, BMI, atrial fibrillation and renal dysfunction. For this reason, natriuretic peptides need to be interpreted within the context of the clinical picture.

• Treatment with neprilysin inhibition will lead to a rise in BNP concentrations, which may obscure the use of this biomarker in patients treated with this class of drug.

• Biomarkers may be useful in identifying patients at risk for but without overt HF.

• Appropriate use of biomarkers in the management of HF may serve to reduce healthcare costs.

• Novel biomarkers such as soluble ST2, highly sensitive troponin T and renal function biomarkers have additive value to the natriuretic peptides in the diagnosis, management and prognostication of HF.