Diagnosing heart failure: The role of natriuretic peptides

I'm Dr. James Januzzi from the Massachusetts General Hospital Heart Center and Harvard Medical School. I'm a clinical trialist and clinician, managing patients with cardiovascular disease, including heart failure. Heart failure is an, unfortunately, very common diagnosis caused by a wide range of different forms of heart disease.

And heart failure by definition is an inability of the heart to maintain normal output and support the needs of the body. Chronic heart failure, again, exceedingly common, may be a subtle diagnosis, accompanied by some shortness of breath and fatigue. But if the body retains too much fluid, a patient may present with acute heart failure with quite evident signs of fluid congestion in the lungs and lower extremities.

Unfortunately, the challenges in heart failure include making the diagnosis confidently, and then managing the patient in a way that will reduce their risk for progression of the diagnosis. Presently, heart failure, unfortunately, has a mortality rate that is actually at, or higher than most forms of cancer, in part because of the challenges in diagnosis and challenges in management.

So when the heart is stressed, as is the case in heart failure, it will release certain hormones into the bloodstream. The idea is that the heart, as an endocrine organ, is trying to unload itself through the release of hormones that have favorable effects in heart failure. Among these released are BNP and NT-proBNP. They come from a common precursor actually, and they're released together, but they're released separately from each other, and they're both measurable in the peripheral blood using widely available assays.

Since the early 2000s, there have been numerous studies performed showing that natriuretic peptides, when added to clinical judgment, very well support the diagnosis of acute and chronic heart failure. When measuring a natriuretic peptide, it's important to add it to clinical judgment. These biomarkers do not replace clinical judgment, but in this context, both BNP and NT-proBNP add substantially to the diagnostic accuracy for the presence of heart failure.

And for this reason, measurements of natriuretic peptides in the emergency department, or office, for the evaluation of suspected or proven heart failure, now carries a class I recommendation in the guidelines. Whether we talk about the United States, Canada, Europe, or other regional guidelines, natriuretic peptide testing has a very enthusiastic endorsement from each of these different guidelines, with class I recommendations, for example, for diagnosis in each of these different documents.

The U.S. guidelines go actually further, giving a class I recommendation also for prognosis, a class II recommendation for in-hospital monitoring for evaluating success of treatment of acute heart failure, as well as a class II recommendation for early detection of heart failure risk in patients such as those with diabetes who are at a very high risk for incident heart failure.

So one can appreciate that the guidelines are really supportive of natriuretic peptide testing in a wide range of different venues. In the future, I envision a couple of very important advances. The first is the development of a more multiple-marker approach for the evaluation, prognostication, and management of heart failure, taking different biomarkers, including potentially imaging biomarkers, and then paneling the information they generate, utilizing artificial intelligence in order to generate panels that help us to better characterize and phenotype individuals with heart failure.

This enhanced characterization of each individual patient with heart failure will therefore open up the clear opportunity for a more precise management of their heart failure with different therapeutic interventions, depending on the information gained from these multiple-marker panels that are developed with an AI-leveraged approach.

Another very important advance in the future is the development of near-patient testing for biomarkers. The concept of having a self-administered fingerstick natriuretic peptide test in order to have the measurement of NT-proBNP not only in the office or in the emergency department, where a fingerstick test would clearly speed the time to diagnosis and triage with respect to decision-making about treatment as well, but also will open up the prospect of home-based fingerstick testing, empowering patients to get involved in their everyday management of heart failure, measuring a natriuretic peptide, and understanding the longitudinal prognostic information that a home fingerstick natriuretic peptide test could provide.

Especially in the current era where virtual care has become such an important component to the management of patients with heart failure, having a fingerstick natriuretic peptide test to support clinical judgment would be a complete game changer.