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Natriuretic peptide-guided management in heart failure

Chioncel, Ovidiu; Collins, Sean P.; Greene, Stephen J.; Ambrosy, Andrew P.; Vaduganathan, Muthiah; Macarie, Cezar; Butler, Javed; Gheorghiade, Mihai

Journal of Cardiovascular Medicine: August 2016 - Volume 17 - Issue 8 - p 556–568
doi: 10.2459/JCM.0000000000000329

Heart failure is a clinical syndrome that manifests from various cardiac and noncardiac abnormalities. Accordingly, rapid and readily accessible methods for diagnosis and risk stratification are invaluable for providing clinical care, deciding allocation of scare resources, and designing selection criteria for clinical trials. Natriuretic peptides represent one of the most important diagnostic and prognostic tools available for the care of heart failure patients. Natriuretic peptide testing has the distinct advantage of objectivity, reproducibility, and widespread availability.

The concept of tailoring heart failure management to achieve a target value of natriuretic peptides has been tested in various clinical trials and may be considered as an effective method for longitudinal biomonitoring and guiding escalation of heart failure therapies with overall favorable results.

Although heart failure trials support efficacy and safety of natriuretic peptide-guided therapy as compared with usual care, the relationship between natriuretic peptide trajectory and clinical benefit has not been uniform across the trials, and certain subgroups have not shown robust benefit. Furthermore, the precise natriuretic peptide value ranges and time intervals of testing are still under investigation. If natriuretic peptides fail to decrease following intensification of therapy, further work is needed to clarify the optimal pharmacologic approach. Despite decreasing natriuretic peptide levels, some patients may present with other high-risk features (e.g. elevated troponin). A multimarker panel investigating multiple pathological processes will likely be an optimal alternative, but this will require prospective validation.

Future research will be needed to clarify the type and magnitude of the target natriuretic peptide therapeutic response, as well as the duration of natriuretic peptide-guided therapy in heart failure patients.

aInstitute of Emergency for Cardiovascular Diseases ‘Professor C.C. Iliescu’, University of Medicine and Pharmacy Carol Davila, Bucuresti, Romania

bDepartment of Emergency Medicine, Vanderbilt University, Nashville, Tennessee

cDivision of Cardiology, Duke University Medical Center, Durham, North Carolina

dBrigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, Massachusetts

eDivision of Cardiology, Health Sciences Center, Stony Brook University, SUNY at Stony Brook, New York

fCenter for Cardiovascular Innovation, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA

Correspondence to Ovidiu Chioncel, MD, PhD, University of Medicine and Pharmacy Carol Davila, Institute of Emergency for Cardiovascular Diseases ‘Professor C.C. Iliescu’, SosFundeni no 258, sect 2, 22328 Bucuresti, RomaniaTel: +40 745400498; e-mail:

Received 1 August, 2015

Revised 6 September, 2015

Accepted 23 September, 2015

© 2016 Italian Federation of Cardiology. All rights reserved.