How a blood test can make a difference in heart failure management

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Heart failure is expected to increase by 46% between 2012 and 2030

Heart failure affects millions of patients and it is a life-threatening condition with poor quality of life, burden of hospitalizations and premature death.1,2 The accuracy of diagnosis, based on history and clinical assessment only, is challenging as symptoms are often difficult to interpret3,4.  And up to 50% of patients can be misdiagnosed with all related adverse impact, such as inappropriate care or treatment adding burden for patients and costs to healthcare systems.4,5 Therefore, further diagnostic procedures are required to confirm the initial diagnosis and ensure the best patient management.

How is heart failure diagnosed?

As a first step to diagnosis, an examination and the patient’s medical history are assessed. Then three further tests and procedures should be performed.1,2 These are an electrocardiogram (ECG), a biomarker (blood test) for natriuretic peptides, and echocardiography to determine any structural and functional impairment of the heart (changes in heart beat rhythm, pumping capacity, wall stress and wall thickness). Interpretation of the results provided by those tests helps in the confirmation or exclusion of the diagnosis of heart failure.

Biomarkers – a characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes, or pharmacologic responses to a therapeutic intervention, in blood.14

Natriuretic peptides – Natriuretic peptides are hormones that are made by the heart when its wall is stretched.

NT-proBNP – N-terminal pro b-type natriuretic peptideis part of the natriuretic peptides family.

What role do natriuretic peptides play in diagnosis?

Natriuretic peptides, like NT-proBNP, provide additional and objective results to aid in the diagnosis and management of heart failure. For example, in patients with suspected symptoms of heart failure, NT-proBNP, which is released in the blood, can help to distinguish cardiac causes from non-cardiac causes, such as of shortness of breath and other symptoms. 1,2,7

Testing natriuretic peptides, such as NT-proBNP, can help in the following situations:

  • In the emergency situation, this aids in the diagnosis, assesses the disease severity and the risk for adverse events.1,2,6 Which can help physicians decide to admit or to discharge patients from the hospital. 3
  • In the general practitioner’s office, this test can help decide whether to refer a patient to the cardiologist for further examination.1,7,8
  • In the longer term, at the cardiologist’s office, or general practitioner, this testing helps physicians to monitor the disease progression and work on the long term management of heart failure.4,5,9,10

If a patient presents with NT-proBNP in his or her blood, then heart failure diagnosis is highly likely, unless the level of the peptide is below a certain threshold.1,2,7

If a patient exhibits high levels of NT-proBNP in his or her blood, over the long term and regardless of medications taken, then the prognosis (clinical outlook) is compromised.9,10,11 Additionally, NT-proBNP, can be used for monitoring heart failure over time and identify which patients are stable or improving, and which are worsening and at high risk of hospitalization or mortality.9,10 Therefore, current guidelines recommend such tests to aid in the diagnosis, to assess the disease severity and get prognostic information all along the heart failure patient journey.1,2

What is NT-proBNP?

  • NT-proBNP is a protein released by the heart when the heart wall is stretched
    NT-proBNP is a protein released by the heart when the heart wall is stretched
  • When NT-proBNP levels in the blood are low, heart failure can be excluded.<sup>1,2,7</sup> Raised NT-proBNP levels in the blood can indicate that someone has heart failure<sup>1,2,12</sup> and levels tend to rise with the disease’s severity.<sup>13</sup>
    When NT-proBNP levels in the blood are low, heart failure can be excluded.1,2,7 Raised NT-proBNP levels in the blood can indicate that someone has heart failure1,2,12 and levels tend to rise with the disease’s severity.13
  • While monitoring patients’ state over time, NT-proBNP levels give information about progression or improvement of patients’ condition. The information given is valid regardless of the medication the patient is taking.<sup>9,10,11</sup>
    While monitoring patients’ state over time, NT-proBNP levels give information about progression or improvement of patients’ condition. The information given is valid regardless of the medication the patient is taking.9,10,11

Having a full clinical picture, with the right objective information, allows physicians to make the best decisions in heart failure management to benefit patients.

   

References

  1. Yancy, et al. (2013). 2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation,128(16):1810-52, 11.
  2. Ponikowski, P. et al. (2016). 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J, 37(27): 2129-2200.
  3. Hummel A. et al. (2015). De novo acute heart failure and acutely decompensated chronic heart failure. Dtsch Arztebl Int; 112: 298–310.
  4. Pang PS et al. (2015). The role of the emergency department in the management of acute heart failure: An international perspective on education and research. Eur Heart J Acute Cardiovasc Care. [Epub ahead of print]
  5. Hobbs, F.D. et al (2002). Reliability of N-terminal pro-brain natriuretic peptide assay in diagnosis of heart failure: cohort study in representative and high risk community populations. BMJ., 324(7352), 1498
  6. Stienen S, al. (2015). Challenging the two concepts in determining the appropriate pre-discharge N-terminal pro-brain natriuretic peptide treatment target in acute decompensated heart failure patients: absolute or relative discharge levels? Eur J Heart Fail;17(9):936-944.
  7. Rutten et al. (2016). EPCCS Practical Guidance on Heart Failure Diagnosis and Management in Primary Care. Web version : http://www.epccs.eu/bestanden/cde7c636129164442711916-EPCCS-2016-HF-Diagnosis-webversion.pdf
  8. Taylor et al. (2017). Primay care REFerral for EchocaRdiogram (REFER) in heart failure : a diagnostic accuracy study. Br J Gen Pract. 2017 Feb;67(655):e94-e102
  9. Januzzi JL, Throughton R. (2013) Are Serial BNP Measurements Useful in Heart Failure Management? Serial Natriuretic Peptide Measurements Are Useful in Heart Failure Management. Circulation;127:500-508.
  10. Zile MR, et al.(2016) Prognostic Implications of changes in N-Terminal Pro-B-Type Natriuretic Peptide in Patients With Heart Failure. J Am Coll Cardio;68:2425-2436.
  11. Jhund PS, McMurray JJV. (2016). The neprilysin pathway in heart failure: a review and guide on the use of sacubitril/valsartan. Heart Published Online First : 26 May 2016. doi:10.1136/heartjnl-2014-306775
  12. All-Party Parliamentary Group on Heart Disease (APPG). Report : Focus on Heart Failure : 10 recommendations to improve care and transform lives. Web : https://www.bhf.org.uk/get-involved/heart-voices/updates-on-our-current-projects/parliamentary-inquiry-into-heart-failure---latest-update
  13. Januzzi JL, et al. (2006). NT-proBNP testing for diagnosis and short-term prognosis in acute destabilized heart failure: an international pooled analysis of 1256 patients: the International Collaborative of NT-proBNP Study. Eur Heart J.;27:330–337.
  14. Strimbu K, Tavel JA. (2010). What are Biomarkers? Curr Opin HIV/AIDS  5(6): 463-466

Tags: Science, Innovation, Diagnostics, Cardiovascular and metabolism