Jaroch, Joanna

Łoboz-Grudzień, Krystyna

English

Via Medica Journals

www.cardiologyjournal.org 1EDITORIALCardiology Journal2009, Vol. 16, No. 1, pp. 1–3Copyright © 2009 Via MedicaISSN 1897–5593Address for correspondence: Prof. Krystyna Łoboz-Grudzień, Department of Cardiology, T. Marciniak Hospital,Traugutta 116, 50–420 Wrocław, Poland, e-mail: kloboz@wp.plNatriuretic peptides in heart failure:Their role in daily practiceKrystyna Łoboz-Grudzień, Joanna JarochDepartment of Cardiology, T. Marciniak Hospital, Wrocław Medical University,Public Health Faculty, Wrocław, PolandArticle p. 43Natriuretic peptides (NP) are volume sensitivehormones that have attracted the interest of inve-stigators in the setting of heart failure (HF) duringrecent years. NP levels may reflect the end-diasto-lic wall stress which is elevated by both increasingfilling pressure and left ventricular dilatation.Brain natriuretic peptide (BNP) and N-terminal proB-type natriuretic peptide (NT-proBNP) have a ne-gative correlation with left ventricular systolic func-tion and have been proposed as diagnostic tools andprognostic markers in HF patients [1, 2]. Cardio-vascular guidelines recommend that both peptidesshould be considered equal [1].The value of BNP and NT-proBNPin daily diagnostic practiceMany studies have shown that the measure-ment of BNP and NT-proBNP can distinguish pa-tients with acutely decompensated HF from thosewho present with other causes of dyspnea. The BNPthreshold level of 100 pg/mL was based on studiesof patients with acutely decompensated HF ratherthan chronic HF. However, the NP levels cannotbe used to differentiate systolic from diastolic dys-function; their measurement might be used to findpatients with HF in the general community, toquantify symptoms and functional limitations, andto predict the risk of cardiovascular events. In theinterpretation of plasma NP levels several factorssuch as age, sex, renal function, cardiac rhythm,obesity, and drug therapy should be taken into ac-count [3–5]. The clinical application of both NPsexceeds their use as rule-out blood tests for HF.The value of BNP and NT-proBNPin quantifying functional capacity During recent years the parameters of cardio-pulmonary exercise have provided the more objec-tive assessment of functional capacity in patientswith HF than New York Heart Association (NYHA)class. However, there is a limited relation betweenmaximal oxygen consumption and parameters of se-verity of HF, such as NYHA functional class and leftventricular ejection fraction (LVEF). It has recentlybeen suggested that plasma BNP levels are relatedto VO2 at peak of exercise and could be a predictorof impaired exercise capacity in patients with HF[6–8]. In this issue of ”Cardiology Journal”, Koç etal. [9] present the usefulness of NT-pro BNP for theprediction of low functional capacity (FC), decreasedLVEF, and the identification of patients at highestrisk of future cardiovascular events. In the asses-sment of FC, the exercise test has been used, andthe cutoff value for NT-proBNP in the predictionof FC < 5 METs was defined [9]. The relationshipbetween NP and the functional capacity may beexplained by the fact that patients with an elevatedrest left ventricular diastolic pressure are prone tothe marked elevation of the capillary wedge pres-sure during exercise.What is the role of BNP and NT-proBNPin predicting low LVEF?Echocardiographic LVEF is an arbitrary and ob-jective marker of cardiac dysfunction and is helpfulto identify patients with poor prognosis. Althoughechocardiography remains a gold standard for thedetection of left ventricular dysfunction, NPs areattractive for screening for left ventricular systolic2Cardiology Journal 2009, Vol. 16, No. 1www.cardiologyjournal.orgdysfunction in asymptomatic populations with sub-clinical disease [10]. In the study of Koç et al. [9],a strong negative correlation between NT-proBNPand ejection fraction was found and an NT-proBNPcut-off value was defined for the prediction of LVEF< 30% in a population with a broad spectrum ofNYHA classes (I–IV). Hence, it could be supposedthat NP might replace ejection fraction in daily prac-tice. Hetmanski et al. [11] measured plasma BNPvalues and compared them to echocardiographicmeasurements of left ventricular function in 653prescribed loop diuretic patients in a large commu-nity based population. The study demonstrated a si-gnificant correlation between plasma BNP andechocardiographic ejection fraction. However, thearea under the ROC curve was 0.587 indicating poorsensitivity and specifity in diagnosis of HF in thegeneral community, which is supported by the widerange of values of BNP. Tang et al. [12] reportedthat in symptomatic patients up to 21% have levels ofBNP below the threshold criteria value < 100 pg/mL.The suggested explanation is that patients with end--stage HF may have very low NP levels because theability of their ventricles to release NP may havebecome exhausted; another explanation could bethat they respond to the optimal therapy. The in-traindividual heterogeneity of plasma BNP valuemight affect our ability to use a single “cutoff” va-lue as a target to guide therapy. Hence, there isa lack of evidence supporting the concept that NPmay replace ejection fraction. The complex evalu-ation joining BNP and imaging test seems to bea rational approach.The value of NP in the evaluation ofleft ventricular diastolic dysfunctionLeft ventricular diastolic dysfunction is a com-mon finding in patients with left ventricular systo-lic dysfunction, and a restrictive filling pattern es-timated by Doppler echocardiography is associatedwith an increased mortality rate. BNP can be con-sidered the most powerful predictor of the restric-tive pattern in patients with severe left ventriculardysfunction [13, 14].The severity of diastolic dysfunction is corre-lated to the increased levels of both BNP andNT-proBNP. It is interesting that in the study byKoç et al. [9] linear regression analysis showed thatleft atrial end-diastolic dimension and NT-proBNPare the most significant predictors for left ventri-cular E/A ratio, reflecting the restrictive filling pat-tern. The restrictive filling pattern is associatedwith increasing left ventricular end-diastolic and leftatrial pressure. Furtermore Lubien et al. [15] repor-ted that BNP can detect the presence of diastolicabnormalities even in patients with normal systo-lic function, but they were not able to differentiatethe various diastolic filling patterns.The use of BNP and NT-proBNPas prognostic markers in heart failureThe prognostic value of risk factors such asejection fraction, complex arrhythmia, and heartfailure symptoms is limited [16]. There are severaldata regarding prognostic implications of differentneurohormonal markers, including BNP andNT-proBNP. NT-proBNP was superior to LVEF inpredicting mortality and heart failure occurrence inthe Australia/New Zealand Heart Failure Study andin the COPERNICUS NT-proBNP substudy [17, 18].In accordance with those studies, the current pa-per by Koç et al. [9] indicated that among severalvariables only NT-proBNP, left ventricular massindex, and resting heart rate were independent pre-dictors of future cardiovascular events, but notLVEF. The authors also defined the cut-off valueof NT-proBNP for the prediction of cardiovascularevents. However, to define cutoff points for quan-tifying the severity of HF and for risk stratification,further studies based on large cohorts are required.Recently, NP levels have been shown to bemodulated by medication. The relationship betwe-en a drop in NP level and the improvement of symp-toms suggests that NP tailored therapy may be anattractive approach in future.References1. Maisel A, Mueller Ch, Adams K et al. State of the art: Usingnatriuretic peptide levels in clinical practice. Eur J Heart Fail,2008; 10: 824–839.2. Pfister R, Scholz M, Wielckens K, Erdmann F, Schneider LA.Use of NT-proBNP in routine testing and comparison to BNP.Eur J Heart Fail, 2004; 6: 289–293.3. Morrison KL, Harrison A, Krishnaswamy P, Kazanegra R,Clopton P, Maisel A. Utility of rapid B-natriuretic peptide (BNP)assay in differentiating CHF from lung disease in patients withdyspnea. J Am Coll Cardiol, 2002; 39: 202–209.4. Packer M. Should B-type natriuretic peptide be measured rou-tinely to guide the diagnosis and management of chronic heartfailure? Circulation, 2003; 108: 2950–2953.5. Januzzi Jr JL, Camargo CA, Anwaruddin S et al. The N-terminalpro-BNP investigation of dyspnea in the emergency department(PRIDE) study. Am J Cardiol, 2005; 95: 948–954.6. Kruger S, Graf J, Kunz D, Stickel T, Hanrath P, Janssens U.Brain natriuretic peptide levels predict functional capacity inpatients with chronic heart failure. J Am Coll Cardiol, 2002; 40:718–722.3Krystyna Łoboz-Grudzień, Joanna Jaroch, Natriuretic peptides in heart failurewww.cardiologyjournal.orgç7. Williams SG, Ng LL, O Brien RJ, Taylor S, Li YF, Tan LB.Comparison of plasma N-brain natriuretic peptide, peak oxygenconsumption and left ventricular fraction for severity of chronicheart failure. Am J Cardiol, 2004; 93: 1560–1561.8. Passino C, Poletti R, Bramanti F, Prontera C, Clerico A, Emdin M.Neuro-hormonal activation predicts ventilatory response toexercise and functional capacity in patients with heart failure.Eur J Heart Fail, 2006; 8: 46–53.9. Koç M, Bozkurt A, Sahin DY, Ünal I, Acartürk E. Cutoff valuesof NT-proBNP for the prediction of low functional capacity, de-creased ejection fraction and cardiovascular events in patientswith heart failure. Cardiol J, 2009; 16: 43–51.10. Redfield MM, Rodeheffer RJ, Jacobsen SJ, Mahoney DW, Bailey KR,Burnett JC. Plasma brain natriuretic peptide to detect preclinicalventricular systolic or diastolic dysfunction. Circulation, 2004;109: 3176–3181.11. Hetmanski DJ, Sparrow NJ, Curtis S, Cowley AJ. Failure of plas-ma brain natriuretic peptide to identify left ventricular systolicdysfunction in the community. Heart, 2000; 84: 440–441.12. Tang WHW, Girod JP, Lee MJ et al. Plasma B-type natriureticpeptide levels in ambulatory patients with established chronic symp-tomatic systolic heart failure. Circulation, 2003; 108: 2964– 2966.13. Yu CM, Sanderson JE, Shum IOL et al. Diastolic dysfunction andnatriuretic peptides in systolic heart failure. Eur Heart J, 1996;17: 1694–1702.14. Catuzzo B, Ciancamerla F, Bobbio M, Longo M, Trevi GP. Inpatients with severe systolic dysfunction only brain natriureticpeptide is related to diastolic restrictive pattern. J Cardiol Fail,2003; 9: 303–310.15. Lubien E, DeMaria A, Krishnaswamy P et al. Utility of B-natriureticpeptide in detecting diastolic dysfunction: Comparison with Dop-pler velocity recordings. Circulation, 2002; 105: 595–601.16. Cowburn PJ, Cleland JG, Coats AJ, Komajda M. Risk stratifica-tion in chronic heart failure. Eur Heart J, 1998; 19:  696–710..17. Hartmann F, Packer M, Coats AJS et al. NT-proBNP in severechronic heart failure: Rationale, design and preliminary resultsof the COPERNICUS NT-proBNP substudy. Eur J Heart Fail,2004; 6: 343–350.18. Richards AM, Doughty R, Nicholls MJ et al. Plasma N-terminalpro-brain natriuretic peptide and adrenomedullin: Prognos-tic utility and prediction of benefit from carvedilol in chronicischaemic left ventricular dysfunction. Australia-NewZealand Heart Failure Group. J Am Coll Cardiol, 2001; 37:1781–1787.

Natriuretic peptides in heart failure: Their role in daily practice

https://journals.viamedica.pl/cardiology_journal/article/download/21529/17133

Natriuretic peptides in heart failure: Their role in daily practice

Abstract

Similar works

Full text

Available Versions

Via Medica Journals