The potential value of integrated natriuretic peptide and echo-guided heart failure management

Cardiovascular Ultrasound

Review

Mario Marzilli¹  Maria Chiara Scali¹  Frank Lloyd Dini¹  Anca Simioniuc¹ 

[1] Unità Operativa Malattie Cardiovascolari 1, Dipartimento Cardio-Toracico e Vascolare, Azienda Ospedaliera-Universitaria Pisana, Via Paradisa, 2, 56124, Pisa, Italy;

关键词: Biomarkers;    B-lines;    Echocardiography;    Heart Failure;    Natriuretic peptide;   

DOI  :  10.1186/1476-7120-12-27

 received in 2014-04-10, accepted in 2014-07-07,  发布年份 2014

来源: Springer

【 摘 要 】

There is increasing interest in guiding Heart Failure (HF) therapy with Brain Natriuretic Peptide (BNP) or N-terminal prohormone of Brain Natriuretic Peptide (NT-proBNP), with the goal of lowering concentrations of these markers (and maintaining their suppression) as part of the therapeutic approach in HF. However, recent European Society of Cardiology (ESC) and American Heart Association/ American College of Cardiology (AHA/ACC) guidelines did not recommend biomarker-guided therapy in the management of HF patients. This has likely to do with the conceptual, methodological, and practical limitations of the Natriuretic Peptides (NP)-based approach, including biological variability, slow time-course, poor specificity, cost and venipuncture, as well as to the lack of conclusive scientific evidence after 15 years of intensive scientific work and industry investment in the field. An increase in NP can be associated with accumulation of extra-vascular lung water, which is a sign of impending acute heart failure. If this is the case, an higher dose of loop diuretics will improve symptoms. However, if no lung congestion is present, diuretics will show no benefit and even harm. It is only a combined clinical, bio-humoral (for instance with evaluation of renal function) and echocardiographic assessment which may unmask the pathophysiological (and possibly therapeutic) heterogeneity underlying the same clinical and NP picture. Increase in B-lines will trigger increase of loop diuretics (or dialysis); the marked increase in mitral insufficiency (at baseline or during exercise) will lead to increase in vasodilators and to consider mitral valve repair; the presence of substantial inotropic reserve during stress will give a substantially higher chance of benefit to beta-blocker or Cardiac Resynchronization Therapy (CRT). To each patient its own therapy, not with a "blind date" with symptoms and NP and carpet bombing with drugs, but with an open-eye targeted approach on the mechanism predominant in that individual patient. A monocular, specialistic, unidimensional approach to HF can miss its pathogenetic and clinical complexity, which only can be overcome with an integrated, versatile and tailored approach.

【 授权许可】

CC BY   
© Scali et al.; licensee BioMed Central Ltd. 2014