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Eur J Heart Fail. 2019 Jun;21(6):715-731. doi: 10.1002/ejhf.1494.

Heart Failure Association of the European Society of Cardiology practical guidance on the use of natriuretic peptide concentrations.

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Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland.
Department of Cardiology, St. Vincent's University Hospital, Dublin, Ireland.
University of Groningen, University Medical Center, Groningen, Department of Cardiology, The Netherlands.
University of California, San Diego, CA, USA.
Robertson Institute of Biostatistics and Clinical Trials Unit, University of Glasgow, Glasgow, UK.
University of Warwick, Coventry, UK.
Monash University, Melbourne, Australia.
Pharmacology, Centre of Clinical and Experimental Medicine, San Raffaele Pisana Scientific Institute, Rome, Italy.
Institute of Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy.
Université de Paris, APHP Département d'Anethésie-Réanimation Hôpitaux Universitaires Saint Louis Lariboisière, Paris, France.
Department of Cardiology, University Heart Centre, University Hospital Zurich, Zurich, Switzerland.
Department of Internal Medicine, General Hospital Murska Sobota, Murska Sobota, Slovenia.
Faculty of Medicine, University of Ljubljana, Slovenia.
Department of Cardiology, Athens University Hospital Attikon, University of Athens, Greece.
University of Cyprus, Medical School, Nicosia, Cyprus.
Faculty of Medicine, University of Belgrade, Belgrade, Serbia.
Heart Institute, Hospital Universitari Germans Trias i Pujol, CIBERCV, Barcelona, Spain.
Department of Medicine, Autonomous University of Barcelona, Barcelona, Spain.
Department of Clinical Pathology, Hospital of Bolzano, Bolzano, Italy.
Christchurch Heart Institute, Uinversity of Otago, New Zealand.
Cardiovascular Research Institute, National University of Singapore, Singapore.
Cardiology Division of the Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.


Natriuretic peptide [NP; B-type NP (BNP), N-terminal proBNP (NT-proBNP), and midregional proANP (MR-proANP)] concentrations are quantitative plasma biomarkers for the presence and severity of haemodynamic cardiac stress and heart failure (HF). End-diastolic wall stress, intracardiac filling pressures, and intracardiac volumes seem to be the dominant triggers. This paper details the most important indications for NPs and highlights 11 key principles underlying their clinical use shown below. NPs should always be used in conjunction with all other clinical information. NPs are reasonable surrogates for intracardiac volumes and filling pressures. NPs should be measured in all patients presenting with symptoms suggestive of HF such as dyspnoea and/or fatigue, as their use facilitates the early diagnosis and risk stratification of HF. NPs have very high diagnostic accuracy in discriminating HF from other causes of dyspnoea: the higher the NP, the higher the likelihood that dyspnoea is caused by HF. Optimal NP cut-off concentrations for the diagnosis of acute HF (very high filling pressures) in patients presenting to the emergency department with acute dyspnoea are higher compared with those used in the diagnosis of chronic HF in patients with dyspnoea on exertion (mild increase in filling pressures at rest). Obese patients have lower NP concentrations, mandating the use of lower cut-off concentrations (about 50% lower). In stable HF patients, but also in patients with other cardiac disorders such as myocardial infarction, valvular heart disease, atrial fibrillation or pulmonary embolism, NP concentrations have high prognostic accuracy for death and HF hospitalization. Screening with NPs for the early detection of relevant cardiac disease including left ventricular systolic dysfunction in patients with cardiovascular risk factors may help to identify patients at increased risk, therefore allowing targeted preventive measures to prevent HF. BNP, NT-proBNP and MR-proANP have comparable diagnostic and prognostic accuracy. In patients with shock, NPs cannot be used to identify cause (e.g. cardiogenic vs. septic shock), but remain prognostic. NPs cannot identify the underlying cause of HF and, therefore, if elevated, must always be used in conjunction with cardiac imaging.


Cut-off concentrations; Heart failure; Natriuretic peptides


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