Copyright © 2004 by the European Society of Cardiology.
Letter to the Editor
B-type natriuretic peptide serum levels in acute heart failure: Reply
Clinical Cardiology, National Heart, Lung Institute, Dovehouse Street, London SW3 6LY, UK
* Tel.: +44-2073518856; fax: +44-2073518148
E-mail address: m.cowie{at}imperial.ac.uk
Our review1 summarises the evidence of the clinical role of plasma BNP measurements in the management of patients in a variety of clinical settings and situations. As is clearly stated in the paper, and as all experienced physicians will know, BNP should not be used as a `stand alone' test but should be interpreted in the clinical context. Nevertheless, the results of studies published to date (and further studies currently reporting at scientific meetings but not yet published in full) support the diagnostic utility of BNP measurement, particularly in patients with new symptoms. This is well accepted in the current ESC guidelines on the diagnosis of heart failure.2
Fillipatos and colleagues point out that the definition of `acute' heart failure is still disputed. Indeed this is the case and the forthcoming guidelines from the ESC on acute heart failure are to be welcomed as they are likely to confirm the value of the measurement of plasma BNP in aiding the diagnosis of heart failure. The full evaluation of a patient with acute symptoms of heart failure, whether de novo or as a result of decompensation of chronic heart failure, requires the underlying cardiac abnormality and pathophysiology to be determined. The care of such patients is often poor, and BNP may be a useful aid to the non-expert clinician in raising the suspicion of this diagnosis more rapidly than is often the case. False negatives may occur – particularly if the cardiac dysfunction is sudden or an inappropriately high decision cut-off point for BNP has been selected. However, in usual practice the studies suggest that BNP measurement is a useful diagnostic aid for the clinician and more recent studies suggest that the circulating concentration of BNP can rise within minutes of a cardiac `insult'.3
It is true that plasma BNP concentration rises with age and tends to be higher in women than men. Nevertheless, the huge rise of BNP found in most patients with symptomatic and untreated heart failure appears rather small in comparison to this "physiological" rise and is therefore of little importance in clinical practice. Of course, this would be more relevant if BNP were to be used to screen for asymptomatic LV dysfunction, but this is a very different clinical situation as our review points out.
The metabolic effects of BNP await confirmation in human studies. However, should these confirm that BNP does indeed play a role in tissue-wasting the case for monitoring BNP levels in patients with heart failure becomes yet stronger.
The data and our clinical experience continue to support the value of the measurement of plasma BNP in the management of patients with breathlessness and, particularly, heart failure.
Yours sincerely.
References
- Cowie MR, Jourdain P, Maisel A et al. Clinical applications of B-type natriuretic peptide (BNP) testing. Eur. Heart J. 2003;24:1710–1718.
[Abstract/Free Full Text] - The Task Force for the Diagnosis and Treatment of Chronic Heart Failure, European Society of Cardiology. Guidelines for the diagnosis and treatment of chronic heart failure. Eur Heart J 2001;22:1527–60.
- Cowie MR, Mendez GF. BNP and congestive heart failure. Prog. Cardiovasc. Dis. 2002;44:293–321.[CrossRef][ISI][Medline]
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