Natriuretic peptides in the diagnosis and management of heart failure

Abstract

The natriuretic peptides are a family of related hormones that play a crucial role in cardiovascular homeostasis. They have recently emerged as potentially important clinical markers in heart failure. Recent data have suggested an important role for these markers in establishing the diagnosis of heart failure in patients with unexplained dyspnea in both acute care and ambulatory settings. Other clinical uses of the natriuretic peptides, such as screening for asymptomatic ventricular dysfunction, establishing prognosis or guiding titration of drug therapy, are under investigation but have not yet sufficiently been validated for widespread clinical use.

Box 1

Fig. 1: Receiver operating characteristic (ROC) curve for N-terminal B-type natriuretic peptide fragment (NT-proBNP) in the PRIDE study involving 600 patients presenting to the emergency department with acute dyspnea. Five possible decision thresholds are shown, ranging from 300 to 1000 pg/mL, with corresponding sensitivities and specificities. Reproduced, with permission, from Januzzi et al. © 2005 Elsevier. Additional data provided by Januzzi.

Fig. 2: Performance of acute congestive heart failure score in the diagnosis of heart failure in the derivation cohort from the PRIDE study (light bars) and the validation cohort from New Zealand (dark bars). Modified, with permission, from Baggish et al.

Fig. 3: Nomogram version of Bayes' Theorem. Starting with a patient in whom the diagnosis is uncertain after clinical evaluation (e.g., pretest probability of 50%), a likelihood ratio of 10 or greater for a positive test result is required to rule in disease with reasonable certainty (i.e., post-test probability of 90% or greater), whereas a likelihood ratio of 0.10 or smaller for a negative test result is required to rule out disease with reasonable certainty (i.e., post-test probability of 10% or lower). Adapted, with permission, from Fagan TJ. Nomogram for Bayes' formula. N Engl J Med 1975;293:257. Copyright © 1975 Massachusetts Medical Society. All rights reserved.