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ePaper - CCN Ausgabe - Number 2013-2

Ausgabe 2 - Number 2 · 2013 CCNCCNCCNCCNCCNCCNCCNCCNCCNCCNCCNCCNCCCathlab &athlab &athlab & CCCardiovascularardiovascularardiovascularardiovascularardiovascularardiovascular NNNewsewsews Does Serial Determination of Natriuretic Peptides improve theTreatment? Prof. Dr. med. Christiane E. Angermann Heart failure symptoms are nonspecific. Thus, for a diagnosis of heart failure (HF), guidelines require imaging evidence for car- diac dysfunction, typically echocardiography. If this is not available, natriuretic peptide (NP) measurements can be used as an initial alternative. A normal NP level will rule out HF. Current ESC Guidelines suggest sepa- rate “rule-out” limiting values for the two most frequent types of NP symptomology, i.e. NT-proBNP: <300 pg/mL; BNP: <100 pg/mL for acute, and NT-proBNP: 125 pg/mL; BNP: 35 pg/mL for subacute HF. In addition to symptomatic improvement, the benefits of the current- ly recommended systolic HF drugs and cardiac resynchronization therapy include reduction in morbidity and mortality and an improved qua- lity of life. Nevertheless, these drug therapies are frequently underdosed or too seldom prescribed. Individualized treatment and drug titration are laborious, and require frequent doctor-patient contacts that are chal- lenging to implement in routine practice. Thus, de- spite some advances, the prognosis for symptomatic HF is poor, and is compa- rable to that for common cancer diseases. NP levels are modula- ted by abnormal filling pressure, morphological and functional cardiac an- omalies, and cardiac arrhythmia. Treatments that affect these factors favorably will lower elevated NP levels (Table 1). By contrast, comor- bidities such as kidney failure, anemia, or inflammation will lead to elevated NP levels. Against this background, a number of studies have investigated the hypothesis that NP-guided HF therapies can improve the patient’s care and prognosis, with some neutral results and some positive. Two meta-analyses were recently published covering results obtained from appr. 2700 patients. In each case, the results showed that NP- guided HF therapies were associated with better titration of HF drugs and significantly lower morbidity and mortality. The authors conclu- ded that therapeutic progress might be delayed in at-risk patients when NP monitoring is not used, as doctors needed the “kick” of the elevated NP levels to trigger treatment. What does this mean for current practice? Certainly that NP is an ex- cellent prognostic marker. However, there is little evidence to support the use of NP values as the only trigger for modifying treatment in individual cases. On the one hand, we recommend a guideline that HF drugs be titrated to the maximum tolerated dose in all patients, and likewise in the not infrequent cases in which the NP level is only slightly elevated despite impaired pumping function. On the other hand, optimal NP levels are frequently illusory, especially in elderly, polymorbid patients. The urgent issue of insufficient and inappropriate treatment can- not be resolved solely by clinical laboratory testing, but requires evidence-based medical treatment and comprehensive care designed for the individual patient, and the adoption of these measures must be adequately reflected in the reimbursement system. Address for Correspondence Professor Dr. C. E. Angermann Med. Klinik Poliklinik und Poliklinik I / Deutsches Zentrum für Herzin- suffizienz Würzburg Universität und Universitätsklinikum Würzburg Straubmühlweg 2a D-97078 Würzburg Tel.: 0931 201 46360 Fax: 0931 201 646360 Email KOLUMNE / COLUMN HERzINSUFFIzIENz / HEART FAILURE 45