Heart failure syndrome consists of chronic compensated heart failure with associated periods of acute decompensation triggered by a variety of different factors such as hypertension, acute coronary syndrome (ACS), arrhythmias, infections, renal dysfunction, medication or dietary nonadherence, and medications.1
The American College of Cardiology/American Heart Association (ACC/AHA) 2013 guidelines recommend measuring ejection fraction by echocardiography, nuclear testing, or magnetic resonance imaging (MRI) for assessment of left ventricular function and structure.2
Often referred to as systolic heart failure, the definition of HFrEF varies; however, current guidelines define HFrEF as occurring in patients with heart failure and EF ≤40%. Studies using this definition have found a prevalence of approximately 50% in patients hospitalized for heart failure. 2,5,6
While there are established therapeutic options to treat HFrEF, morbidity and mortality rates remain high2
*A subset of patients with HFpEF previously had HFrEF
Often referred to as diastolic heart failure, HFpEF has been defined using several different criteria and has been variably classified as ejection fraction (EF) >40%, >45%, >50%, and ≥50%. Some studies suggest that the prevalence of HFpEF is increasing.2,5
The assessment of patients with suspected heart failure should include a thorough medical history and physical examination; routine laboratory tests, imaging examinations, and biomarkers determine the type and severity of heart failure. Some of the more common evaluations are estimates of jugular venous pressure, tests for peripheral edema, chest x-rays, echocardiograms, Doppler flow studies, and sometimes nuclear tests or MRI.2
Natriuretic peptides are one of the most important counterregulatory systems activated in heart failure. American College of Cardiology/American Heart Association (ACC/AHA) 2013 guidelines recommend the use of biomarkers B-type natriuretic peptide (BNP) or N-terminal pro–B-type natriuretic peptide (NT-proBNP) in the initial diagnosis of ambulatory patients with dyspnea and in episodes of acutely decompensated heart failure, and additionally, to establish prognosis of chronic or acute heart failure. Elevated BNP and NT-proBNP levels may be useful in the diagnosis of heart failure.1,2
While the results of BNP or NT-proBNP are useful in the diagnosis of heart failure, they should always be used to supplement clinical judgment and should not replace it. Elevation of these peptides may occur not only with left ventricular systolic dysfunction, but also with age, renal failure, and with other conditions such as valvular heart disease, pulmonary hypertension, ischemic heart disease, and atrial arrhythmias. US guidelines do not provide a cut point for interpretation of specific BNP or NT-proBNP values; however, pivotal studies used results of BNP and NT-proBNP for diagnosis as follows1:
In evaluation of ambulatory patients, the optimized cut-off values from emergency department studies should not be used; lower values are mandatory, optimized for their negative predictive value to exclude—rather than to identify—heart failure. Age stratification of values may also be valuable. Please note that BNP and NT-proBNP levels may vary by lab.1,7
Although some trials suggest there may be value to using BNP or NT-proBNP to monitor a patient's progress, current recommendations state that the usefulness of serial measurement of BNP or NT-proBNP to reduce hospitalization or mortality in patients with heart failure is not well established.2
A large National Institutes of Health (NIH) trial, GUIDE-IT, is currently underway to determine the effectiveness of a biomarker-guided therapeutic strategy with serial measurement of NT-proBNP in high-risk patients with left ventricular systolic dysfunction.8
Treatment strategies combining multiple biomarkers may ultimately be beneficial in guiding heart failure therapy.2
As a response to cardiac stress, cardiomyocytes synthesize the prohormone, pro-BNP, which is then proteolytically cleaved by furin into two components: NT-proBNP, a biologically inactive N-terminal fragment, and BNP, a biologically active peptide.1
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