Review Article
Natriuretic Peptides: Role in the Diagnosis and Management of Heart Failure: A Scientific Statement From the Heart Failure Association of the European Society of Cardiology, Heart Failure Society of America and Japanese Heart Failure Society

https://doi.org/10.1016/j.cardfail.2023.02.009Get rights and content

ABSTRACT

Natriuretic peptides, brain (B-type) natriuretic peptide (BNP) and N-terminal prohormone of brain natriuretic peptide (NT-proBNP) are globally and most often used for the diagnosis of heart failure (HF). In addition, they can have an important complementary role in the risk stratification of its prognosis. Since the development of angiotensin receptor neprilysin inhibitors (ARNIs), the use of natriuretic peptides as therapeutic agents has grown in importance. The present document is the result of the Trilateral Cooperation Project among the Heart Failure Association of the European Society of Cardiology, the Heart Failure Society of America and the Japanese Heart Failure Society. It represents an expert consensus that aims to provide a comprehensive, up-to-date perspective on natriuretic peptides in the diagnosis and management of HF, with a focus on the following main issues: (1) history and basic research: discovery, production and cardiovascular protection; (2) diagnostic and prognostic biomarkers: acute HF, chronic HF, inclusion/endpoint in clinical trials, and natriuretic peptides-guided therapy; (3) therapeutic use: nesiritide (BNP), carperitide (ANP) and ARNIs; and (4) gaps in knowledge and future directions.

Section snippets

Writing Committee Composition

The HFSA, the Heart Failure Association (HFA) of the ESC, and the JHFS selected the members of the writing committee, which consisted of 28 individuals with domain expertise in biomarkers and management of HF.

Consensus Development

On November 6, 2021, HFA, HFSA and JHFS convened a consensus conference to develop a paper on Natriuretic peptides: Role in the diagnosis and management of heart failure. The work of the writing committee was accomplished via a series of Web conference meetings, along with extensive e-mail

History and Basic Research: Discovery, Production and Cardiovascular Protection

Natriuretic peptide research began in 1956 with the discovery by Kisch of electron-dense granules named atrial-specific granules.4 Twenty years later, in 1981, DeBold found diuretic and vasodilating activity in atrial extract.5 At the end of 1983 and the beginning of 1984, DeBold and Matsuo and Kangawa succeeded in the isolation and identification of amino acid's primary structure independently.6 They also discovered 2 peptides, brain (B-type) natriuretic peptide (BNP) and C-type natriuretic

Diagnostic and Prognostic Implications in Acute and Chronic Settings

Accurate diagnosis and prognosis are essential for optimizing medical care for serious cardiovascular conditions such as HF. Natriuretic peptides play a central role in both the diagnosis of HF as well as in the accurate assessment of short- and long-term prognosis. Given that HF is a clinical syndrome, characterized by a collection of recognizable signs and symptoms, additional diagnostics are of high potential value. Prior frameworks for the diagnosis of ambulatory patients with HF, such as

The Role of Incorporation in Clinical Trials

Natriuretic peptide concentrations have been increasingly incorporated in eligibility criteria for clinical trials involving patients with HF. In this implementation, they serve at least 4 roles. First, natriuretic peptides provide a readily obtained, objective laboratory sign corroborating the diagnosis of HF and are particularly useful in acute HF and HFpEF trials where confounding diseases are more prominent in the presentation (eg, dyspnea from chronic obstructive pulmonary disease

Considerations in Therapeutic Approach

Guidelines from several leading HF societies all provide a Class I recommendation for measuring BNP or NT-proBNP for diagnosis or prognosis assessment in the management of chronic HF.2,3,59 The value of BNP/NT-proBNP for that purpose is, thus, widely acknowledged. However, arguments remain about the usefulness of BNP/NT-proBNP as a guide for medical treatment. Several clinical trials testing relatively small samples assessed the efficacy of BNP-guided therapy and had mixed results, although

Gaps in Knowledge and Future Directions

Despite the primacy of BNP and NT-proBNP as the biomarker standard for predicting prognosis in HF, important caveats regarding their use exist; addressing such questions might be expected to inform newer or more nuanced use of these important biomarkers.

These may be summarized into 3 main areas: (1) mechanistic insights, (2) implications for therapeutic approach, and (3) understanding the role of natriuretic peptides beyond the cardiovascular system.

Conclusion

This statement provides current evidence about the role of natriuretic peptides in the diagnosis and management of HF. It is expected to be scientifically and clinically relevant, with the ability to be of great value. Natriuretic peptides have universal applicability globally and high diagnostic, therapeutic and prognostic validity. We envision that this statement concerning the role of natriuretic peptides in the diagnosis and management of HF may be used by health care professionals in HF,

Take-home Visual Data

Disclosures

HT receives consultancy fees from Boehringer Ingelheim, Bayer Yakuhin, Novartis Pharma, Ono Pharmaceutical, Astra-Zeneca; remuneration from MSD, Astellas Pharma, Pfizer Japan, Bristol-Myers Squibb Company, Otsuka Pharmaceutical, Daiichi Sankyo, Mitsubishi Tanabe Pharma, Boehringer Ingelheim, Takeda Pharmaceutical, Bayer Yakuhin, Novartis Pharma, Kowa Pharmaceutical, Teijin Pharma; manuscript fees from Medical View, Nippon Rinsho; research funding from Actelion Pharmaceuticals Japan, Japan

Role of Funding Source

None.

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